Attention to Detail
Taking a one-second pause to use this HRO tool that is a four letter acronym reduces the probability of making an unintended skill-based error by a factor of ten.
What is S.T.A.R. (Stop, Think, Act, Review)?
This standardized communication tool is used to transfer patient information between caregivers, ensuring key details aren't missed.
What are Standardized Handoffs? or SBAR
In a safety-focused culture, leaders must model and expect the use of this specific term for spelling out words or verifying numerical data.
What is Phonetic & Numeric Clarification?
A leader's questioning attitude encourages staff to perform this vital task whenever they encounter a near miss or actual incident, contributing to a learning culture.
What is Report Problems, Errors, and Events?
Embracing this type of attitude means challenging assumptions and never taking things at face value, especially when patient safety is involved.
What is a Questioning Attitude?
A 3-day-old baby presented to the ED with a suspected umbilical cord infection. The ED MD ordered labs, swabs and blood cultures, and an order was placed to admit the patient to the NICU. The ED nurse communicated to the phlebotomist to wait to draw blood cultures when the peripheral IV was placed in the NICU.
A phone report was given between ED and NICU nursing, and then another RN transported the patient to the NICU. Between these two handoffs key information was missed.
In the NICU antibiotics were started even though the blood cultures had not been drawn. Staff noticed hours later that no blood cultures had been collected even though the patient had received two separate antibiotics.
What key HRO skills & tool could have been used to prevent this error?
What is We Communicate Clearly? Standardized Hand Off
In the S.T.A.R. model, this step refers to the execution of the planned action, ensuring precision and adherence to established protocols.
What is Act?
Staff demonstrate active listening by asking these types of questions to ensure full comprehension and uncover any ambiguities.
What are Asking Clarifying Questions?
This communication process is used to transfer patient information between caregivers, ensuring key details aren't missed.
What are Standardized Handoffs?
Leaders who "communicate clearly" also set the expectation for team members to provide constructive feedback to peers using this HRO tool.
What is Cross checking & Coaching?
As an HRO tool, "Your Questioning Attitude" directly supports this HRO principle, by encouraging exploration of potential mismatches between expected and actual events.
What is Reluctance to Simplify Interpretations (or Preoccupation with Failure)?
An expectant mother at 38 weeks pregnant presented to the OBED having contractions. She was evaluated in the OBED and it was noted in her history that she had low platelets. She also had some concerning fetal heart tracings. The evaluating physician was concerned that Methodist was not the safest hospital for the patient to give birth because of the hospital’s limited platelet supply.
The physician discussed her concerns with the patient, and she decided to discharge the patient with instructions to drive herself to a larger hospital that had more blood products. The nurse taking care of the patient was hesitant about this plan but did not speak up. The patient drove herself to a different hospital as recommended by the physician. She later delivered via emergency C-section.
What key HRO skill & tool could have been used to prevent this potentially unsafe discharge?
What is Accountable Team Members? (Speak Up with Respect using C.U.S.S.)
In our pursuit of zero harm, this HRO skill reminds us to be careful about everything we do, even those things that become routine.
What is Attention to Detail?
When receiving verbal orders or critical lab values, this specific technique ensures the information was correctly heard and understood.
What is Read Back / Repeat Back?
In a safety-focused culture, leaders must model and expect the use of this specific term for spelling out words or verifying numerical data.
What is Phonetic & Numeric Clarification?
Using "C.U.S.S. with Respect" (Concern, Uncomfortable, Safety Issue) is a structured way for team members to engage in this proactive behavior.
What is Speak-Up?
The consistent practice of "Your Questioning Attitude," especially through "Pause, Question, Confirm," strengthens this core HRO principle by catching potential errors before they escalate.
What is Preoccupation with Failure (or Commitment to Resilience)?
A patient was receiving a knee arthroscopy at the Outpatient Surgery Center. The physician gave a verbal order for a nerve block cocktail to include morphine. The RN pulled hydromorphone (Dilaudid) instead and a 5 mg dose was administered. The patient became overly sedated in the PACU, requiring rescue breaths and Narcan to reverse the opioid oversedation. The patient was sent to the ED for further evaluation because she continued to be sedated despite five doses of Narcan. The patient was observed in the ED and was able to be discharged home without further interventions.
What key HRO skill could have been used to prevent this medication error?
What is Attention to Detail? STAR
After completing a task, especially a critical one, this final S.T.A.R. step involves reflecting on the outcome and identifying any lessons learned or areas for improvement.
What is Review?
When a nurse asks a provider, "Could you please clarify the dosage of medication X, as it seems a bit high for this patient's weight?", they are primarily demonstrating this action.
What is Asking Clarifying Questions?
This four-part communication framework helps organize thoughts and present information concisely and effectively, especially in urgent situations.
What is SBAR (Situation, Background, Assessment, Recommendation)?
This HRO skill addresses the problem of power distance, where workplace structures may otherwise discourage some team members from speaking up
What is Accountable Team Members?
This term describes the general mindset in an HRO where team members are encouraged to actively seek discrepancies and challenge assumptions.
What is a Questioning Attitude?
An 83 year old male patient was admitted with severe abdominal pain and found to have an intestinal blockage. A colectomy and ileostomy were performed. On post-op day 1, the NG tube was discontinued and the patient was started on clear liquids. On post-op day 2, the nurse noted the patient’s abdomen was firm. On post-op day 3, the abdomen continued to be firm, with hypoactive bowel sounds, one instance of emesis and 8 out of 10 abdominal pain. The nausea and pain were reported to the MD and the patient was medicated for both. That evening the patient was found unresponsive, with copious bilious fluids coming from his mouth. Attempts were made to resuscitate the patient but he ultimately expired.
What key HRO skill could have been used to prevent this medication error?
What is Your Questioning attitude? Pause, Question, Confirm.
This first step in the S.T.A.R. process emphasizes a moment of deliberate halt before proceeding, crucial for preventing automatic errors.
What is Stop?
This HRO skill teaches ways to not rely on memory and shows us how to always clarify information.
What is Listen to Understand?
Beyond just documentation, this principle emphasizes recording information correctly and precisely, ensuring accuracy for all future care.
What is Document Accurately?
Beyond just hearing words, a leader who truly "listens carefully" fosters an environment where team members feel safe to engage in this crucial communication technique.
What is Speak-Up using C.U.S.S. with Respect?
A team member who receives a complex verbal order, then asks for clarification, and finally repeats the order back to the prescriber, is executing this full three-step process.
What is Pause, Question, and Confirm?
There were two patients being care for in the ED with the same last name, roomed text to each other. One was a male, the other female. The male patient needed to be intubated. The MD verbalized to the team in the room that this patient was hyperkalemic and he wanted to treat the high potassium before intubating. He gave verbal orders for four hyperkalemia medications. The medications were pulled by the nurses using override, and were given without scanning and prior to pharmacist verification. After the medications were given the team learned that the physician was mistaken about which patient was hyperkalemic. He had given verbal medication orders for the wrong patient with the same last name as the correct patient. No harm came to the patient and the error was disclosed to their family.
What key HRO tools might have been able to prevent this error?
What is Listen to Understand? Read Back/ Repeat Back