Michael Alton, director of the Health System’s Patient Safety Office/Patient Safety Center and a Six Sigma black belt, is pleased with the way the hospital is using the Six Sigma methodology to reduce the risks of moderate sedation for children.
“When we started looking at safety issues in the pediatric areas, we realized that moderate sedation is performed on children at multiple places throughout the hospital " from the inpatient units to radiology to the Emergency Department " and we didn’t have consistent practices about how to do it with the lowest risk. We weren’t experiencing a high number of adverse events but we knew that the risks were still there and that unless we did something, there might be a problem in the future,” he says.
With very few actual safety incidents to investigate, the Six Sigma team turned to an FMEA " a Failure Mode and Effect Analysis. “This is a tool that helps the team evaluate the possible ways a patient care process can fail, and what can be done to make it safer,” explains Alton. The team looked at areas such as when and where providers sedate patients, patient monitoring, team communication and clinical documentation. They focused on 16 specific ways a mistake might happen, and determined ways to “mistake-proof” those portion of the procedure.
For instance, procedural checklists " similar to the pre-flight checklists used by airlines " are being incorporated into the existing moderate sedation documentation tools to ensure that the health care team completes all required elements before starting the procedure. Another mistake-proofing step is the use of a moderate sedation “medication algorithm” currently being developed by the 5100/5300 safety team in collaboration with Pediatric Anesthesia. This algorithm will provide both physicians and nurses with clinical guidance on drugs and dosages for specific procedures, minimizing the potential for adverse drug events and enhancing team communication.
“The FMEA tool has a way to score the risk of a procedure,” says Alton. “When we initially used the tool, we had an initial mean risk score of 11.94 on a 16 point scale. After we completed the project, the mean risk score dropped to 4.94.”
The Moderate Sedation Six Sigma team is currently finalizing the new recommendations on the 5100 and 5300 pediatric inpatient units, and plans to begin implementing the approved recommendations across all of the pediatric units and ancillary departments. A second team is completing a follow-up FMEA focusing on moderate sedation in pediatric radiology.
