September 2004
Safety Tip # 1 - Effective leaders delegate so that they can regulate. During times of heavy workload, leaders should manage the situation while others manage the actual tasks.
Why? Research has shown that such a strategy reduces multitasking and improves decision-making and vigilance. Leaders who fail to delegate during high workload risk increased errors and accidents due to the burden of trying to simultaneously managing the tasks, the team, and the environment. Evidence of this phenomenon comes from a handy statistic in commercial aviation. The National Transportation Safety Board found a disproportionately high percentage of aviation accidents (over 80%) occur when the captain is the pilot doing the actual flying and the first officer is the pilot "not flying." These captains are overloaded as they try to accomplish flight tasks and command duties at the same time.
An example: in our own industry involved a charge nurse failing to delegate. A patient with a history of an elevated heart rate spontaneously went into a fast irregular rhythm. The bedside nurse called out for help when the rhythm caused a significant drop in blood pressure. The charge nurse, three additional bedside nurses, and the medical resident arrived at the bedside. The resident ordered an intravenous medication, which the charge nurse went to obtain and then administered. Rather than delegate the task to the other staff members, which would allow her to better supervise and document the efforts of the staff, the charge nurse sent the other three nurses away stating she could handle the situation. The patient did not respond to the medication and the physician ordered that the patient be cardioverted (an electrical shock to trigger a normal rhythm) and that a continuous medication be given intravenously. The charge nurse left to mix the medication and get the defibrillator machine. The charge nurse returned to administer the electric shock with the physician present. The patient continued to deteriorate and needed additional treatment that was delayed because the charge nurse did not delegate tasks to the other team members. The patient suffered mild heart ischemia, and a low oxygen level that required mechanical ventilation to assist breathing, and resulted in a prolonged ICU stay.
Reference: Sexton, J.B. (2004). Golden Rules of Group Interaction in High Risk Environments: Evidence based suggestions for improving performance. Book. Gottlieb Daimler and Karl Benz Foundation and Swiss Re Centre for Global Dialogue. Ladenburg & Rueschlikon. National Transportation Safety Board (1994), Safety Study: A Review of Flight crew-involved, Major Accidents of U.S. Air Carriers, 1978 through 1990, PB94-917001, NTSB/SS-94/01, Author, Washington, DC.
Safety Tip # 2 - Ask early if you have a question about a task to be done later.
Why? Mistakes often occur because care team members lack clarity about exactly what they are to do, or when they are to do it. Research has shown that asking a question early (rather than asking the same question later) not only reduces the risk of failure or injury, but also saves time and reduces the stress that comes with ambiguity and uncertainty.
An example: An intern joined rounds late. At the end of rounds, the senior house officer noted that it was time to remove the first of the two chest tubes in an elderly patient. While everyone present nodded in agreement, the task was given to the late intern, who did not know which tube was placed first and did not feel comfortable asking after having nodded knowingly moments before. He incorrectly assumed the patient was the one that he participated in rounds on. Later, the intern went to carry out the task, and incorrectly removed what looked like the older tube. Had he asked questions when first assigned the task, he would not have removed the wrong chest tube from the wrong patient. This caused the patient respiratory distress requiring placement of another chest tube.
Reference: Sexton, J.B. (2004). Golden Rules of Group Interaction in High Risk Environments: Evidence based suggestions for improving performance. Book. Gottlieb Daimler and Karl Benz Foundation and Swiss Re Centre for Global Dialogue. Ladenburg & Rueschlikon.
Safety Tip # 3 - Lead in a pinch, cede in a cinch (Encourage leadership behavior in unstructured situations but not in routine situations)
Why? Leadership behaviors are most important in situations that are complex, unusual, or high workload. In fact, research has shown that the presence of leadership behaviors during routine or standardized situations is associated with poor outcomes. During routine situations, a leader who is present but does not have to actively engage a technical task should take the opportunity to observe the strengths and weaknesses of the team as this knowledge is critical during less routine situations, when the ability to predict and understand the behaviors of others is essential.
An example: A patient with a very unstable airway and a recent tracheotomy (surgical incision into the trachea through the neck) suddenly suffered an obstructed airway and within a few seconds was experiencing life threatening hypoxia (low blood oxygen levels) and hypotension. The resident and fellow were not sure how to manage the patient, and had been unsuccessfully paging the ICU attending for the past several minutes. A surgical attending unfamiliar with the patient happened upon the scene in the ICU and immediately assumed charge of the patients care. She attempted dilation of the airway unsuccessfully. She requested a scalpel and a replacement trachea, replaced the artificial airway and stabilized the patient while the resident and fellow stepped aside to assist her. Within a few minutes, the patient stabilized and the attending left the care of the patient in the hands of the fellow.
Reference: Kerr, S. and Jermier, J. M. (1978). "Substitutes for leadership: Their Meaning and Measurement." Organizational Behavior and Human performance 22: 375-403 Zaccaro, S., J., A. Rittman, L., et al. (2001). "Team leadership." The Leadership Quarterly 12: 451-483. Sexton, J.B. (2004). Golden Rules of Group Interaction in High Risk Environments: Evidence based suggestions for improving performance. Book. Gottlieb Daimler and Karl Benz Foundation and Swiss Re Centre for Global Dialogue. Ladenburg & Rueschlikon.
Safety Tip # 4 - Increase transparency and reduce ambiguity in multidisciplinary environments using daily goals.
Why? We often lose time and information in multidisciplinary settings because transparency of actions between and within disciplines requires discussions with colleagues from other disciplines in various physical locations with differing degrees of accessibility. Setting public daily goals (click here for an example) for a given patient using a goals sheet attached to a clipboard at each bedside enhances the transparency of actions and intentions between and within disciplines for "this patient, in this bed, today." Daily goals are associated with a 50% decrease in length of stay, by providing a public record of thought processes and decision making by the multidisciplinary team.
An example: During rounds the attending physician and fellow agreed that it was best to gently diurese the patient in order to move toward extubation. The patient had a history of coronary artery disease patient was the one that he part and chronic renal insufficiency (the patient was greater than 10 kg above pre-operative weight). By the end of the day, the patient was stable and progressing according to plan. After evening rounds the attending went home and the senior resident wrote to increase the lasix gtt to 3 mg an hour. This deviation in the plan of care resulted in the patient becoming hypotensive requiring fluid boluses and and a neosynepherine gtt to stabilize the patient's blood pressure. Extubation was delayed and length of stay was increased by 2 days.
Reference: Pronovost, P.J., Berenholtz, S., Dorman, T., Lipsett, P.A., Simmonds, T., and Haraden, C. (2003). Improving communication in the ICU using daily goals. Journal of Critical Care. June; 18(2): 171-5.