Cedars-Sinai Medical Center

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CME Newsletter - May 2014


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A Pause for Patient Safety

New Process Succeeds in Tests, Will Expand Housewide

Sometimes, the best solution is the simplest one. To help prevent the accidental removal of patient tubes and lines, a simple, three-step process, Pause-Clear-Go, has proven so successful that it is being rolled out across the medical center.

"After surgery, patients have so many lines and drains in them that it's easy to overlook one during transport," said Christine Chuey, RN, CN III. "In 3 OR, we were experiencing numerous incidents of lines and drains that were almost pulled out but were caught at the last minute. We decided to find a way to prevent these near misses in the O.R."

Components of Pause-Clear-Go

  • Pause — the primary care provider calls out "Pause," and everyone stops
  • Clear — the assisting care provider calls out "Lines … Drains … Airway" and the primary care provider answers "All clear"
  • Go — either the primary care provider or assisting provider calls out "Go" to signal that the patient is safe to reposition, turn or transfer

The Medical Intensive Care Unit (MICU) team on 7 Saperstein was experiencing the same problem, which can result in unintended consequences not only for patients, but for their families and care providers. When lines are accidentally pulled out, it can interrupt treatment, cause complications and create distrust between patients and healthcare teams.

The issue simultaneously attracted the attention of two separate unit-based safety project teams: SCORE (Safe Care in the O.R. Every time) and Normalized Deviation.

SCORE is a grass-roots effort that enables front-line surgical staff and physicians to address safety concerns in the O.R. SCORE team leaders include Bruce Gewertz, MD, chair of Surgery and vice president of Interventional Services, Julian Gold, MD, co-chair of Anesthesiology, Bryan Croft, vice president of Service Line Operations, and Jan Decker, RN, director of O.R./Anesthesiology/Surgery Center.

The Normalized Deviation team, led by Neil Romanoff, MD, vice president of Medical Affairs and associate chief medical officer, addresses the small, continuously occurring defects that eventually become "normalized" as part of daily routine.

"In the ICU, the problem with lines usually occurs during repositioning of the patient, because critically ill patients have so many lines attached to them," said Adolfo Famas, RN, assistant nurse manager on 7 Saperstein. "We had an average of one pulled line each month that was related to the repositioning, turning and transferring of patients. Although that may sound like a small number, it's important to us that we ensure it never happens to a single patient."

To address the issue, the SCORE and Normalized Deviation teams began testing the Pause-Clear-Go time-out system prior to moving any patient.

"Following implementation, O.R. staff members have reported a decreased near-miss rate from 64 percent to 28 percent," said Ann Gilligan, RN, MSN-BC, assistant nurse manager in the O.R. "In addition, the MICU has not experienced a single incident since September 2013. As we continue to implement this system housewide, we anticipate that the number of near misses will decline even further."