Improving cardiac surgical care: A work systems approach

Wiegmann, Douglas A.; Eggman, Ashley A.; ElBardissi, Andrew W.; Parker, Sarah; Sundt, Thoralf M.

doi:10.1016/j.apergo.2009.12.008

Cited by 77 publications

(72 citation statements)

References 72 publications

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“…Although spaghetti syndrome has been considered a serious patient care issue for many years, few studies have proposed a solution to this problem. [1][2][3]5,6,10,11,15,16 We hope that the results will reenergize the interest in solving the problem of spaghetti syndrome and lead to the development of protocols and standard processes for use of a simple solution to control entanglement of bedside tubing and wires for all hospitalized patients.…”

Section: Discussionmentioning

confidence: 99%

Managing Spaghetti Syndrome in Critical Care With a Novel Device: A Nursing Perspective

Haynes

Bowers

Young

et al. 2015

Critical Care Nurse

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Background Managing "spaghetti syndrome," the tangle of therapeutic cables, tubes, and cords at patients' bedsides, can be challenging. oBjectives To assess nurses' perceptions of the effectiveness of a novel banding device in management of spaghetti syndrome. Methods A simple color-coded elastomeric banding strap with ribbed flaps was attached to bed rails of adult critical care patients to help organize therapeutic cables, tubes, wires, and cords. Nurses were surveyed before and after use of the bands and after the nursing shift to assess the burden of spaghetti syndrome and the effectiveness of using the bands. results Use of the bands decreased the time spent untangling cords, reduced the frequency of contact of tubing with the floor, and diminished disruptions in care. conclusions Use of a simple flexible latex-free elastomeric band may help organize therapeutic tubing at patients' bedsides and may promote improvements in nursing care. (Critical Care Nurse. 2015;35[6]:38-45) ©2015 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2015321 C ritical care patients often have numerous therapeutic connections (eg, cords, cables, and tubes) at the bedside that can easily become disorganized and tangled, leading to contamination of the connections, nurses' confusion, a physical hazard that increases the risk for falls for both nurses and patients, and the possibility of damage of medical devices.1-6 This phenomenon, known as spaghetti syndrome, makes caring for patients challenging and difficult 1,2 ( Figure 1). Multiple instances of patients' deaths, permanent injury, and life-threatening situations related to entanglement with the cords of medical devices have been reported. 5,[7][8][9][10][11][12][13][14] Ensuring the organization of cords and tubes at a patient's bedside may reduce adverse outcomes such as entanglement of the patient, backflow in tubing, falls by both patients and health care personnel, and connection errors or damage of medical equipment. [5][6][7]12 38 Therapeutic tubing, cables, wires, and cords are a fundamental aspect of daily health care for delivery of medications and fl uids to patients. The often disorganized tubing and cords at the bedside increase the possibility of inadvertently connecting the wrong syringes and tubing and then unintentionally delivering medication or fl uids via the wrong route. In 2006, the Joint Commission issued alerts on tubing misconnections; interventions and procedures to manage and protect medical cords, tubes, and cables as a standard of care, but only a few devices are available to aid in this task. 11,13,15 Few bedside devices for cord control are commercially available, and they vary in complexity and design. The purpose of this study was to test use of a novel simple, sleeved-strap banding device in the management of spaghetti syndrome in a critical care unit and to assess nurses' responses to use of the band. Before the study, no devices or standard protocols were being used to manage the syndrome. MethodsAfter a compa...

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Section: Discussionmentioning

confidence: 99%

Managing Spaghetti Syndrome in Critical Care With a Novel Device: A Nursing Perspective

Haynes

Bowers

Young

et al. 2015

Critical Care Nurse

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“…It also includes elements of action and activity level knowledge artifacts, with detailed specifications of individual actions such as prophylaxis metrics. This increases both the workload and cognitive complexity, which is a known factor leading to stress and error [32] and potential deviations from using the document, i.e. a workaround.…”

Section: Lacks Clear Visibility Of Who Is Doing What By Non Nursesmentioning

confidence: 98%

“…These were found frequently in CPs which are known to improve the quality and safety of medical care [33,32]. A checklist is a set of control norms at the task level [36] in a specific order for example with a norm whenever ochecking action list4 if oaction condition true4then omark action step completed4.…”

Section: Deontic Artefact Findingsmentioning

confidence: 99%

Are clinical documents optimised for patient safety? A critical analysis of patient safety outcomes using the EDA error model

Michell

Tehrani

Liu

2012

Health Policy and Technology

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“…These issues have not been fully addressed at this point, and there is some evidence that fatigue does not significantly impact patient outcomes in cardiac surgery [81][82][83]. Suggestions have been made to incorporate rest breaks into the workday, particularly when the task stress and mental workload are high [60].…”

Section: Personal Readiness Violationsmentioning

confidence: 99%

“…The science of patient safety is relatively new, and much more of the available literature in cardiac surgery relates to identification of hazards rather than proven methods for improvements in patient safety. As eloquently summarized by Wiegmann et al [60], patient safety programs must take a comprehensive work systems approach to correcting the factors that negatively impact the safety of our cardiac surgery patients.…”

Section: Improving Patient Safety In Cardiac Surgery: a Work Systems mentioning

confidence: 99%

Improving Patient Safety in the Cardiac Operating Room: Doing the Right Thing the Right Way, Every Time

Wahr

Abernathy

2014

Curr Anesthesiol Rep

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The past 5 decades have seen an incredible advance in cardiac surgery knowledge, techniques, equipment, skill sets, and outcomes. Even as our average cardiac surgery patient becomes older with more significant cardiac disease and medical comorbidities, mortality continues to decrease. However, many of the deaths that do occur have been shown to be preventable. These preventable deaths are more often due to non-technical errors, such as communication failures, distractions, and disruptions, than to a failure of technical skill or knowledge. Further improvements in patient outcome require optimizing team performance, in both what the team does (evidence-based best practices) and how they do it (optimizing team performance, reduction of error, improved tools and technologies). Interventions such as formal team training, checklists, briefings and debriefings, cognitive aids, and handover tools have been shown to decrease disruptions and reduce patient mortality. Optimizing team performance will require adoption of a just culture, where errors are not met with ''blame and shame'' but as due to system hazards to be resolved, but where personal accountability is also present. The journey to habitual excellence should not be viewed as a draconian elimination of human error, but one of continuous optimization of team performance.

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Improving cardiac surgical care: A work systems approach

Cited by 77 publications

References 72 publications

Managing Spaghetti Syndrome in Critical Care With a Novel Device: A Nursing Perspective

Managing Spaghetti Syndrome in Critical Care With a Novel Device: A Nursing Perspective

Are clinical documents optimised for patient safety? A critical analysis of patient safety outcomes using the EDA error model

Improving Patient Safety in the Cardiac Operating Room: Doing the Right Thing the Right Way, Every Time

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