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Skyscape Blog

Stopping the Line for Patient Safety

Posted by Skyscape on Oct 30, 2018 11:18:53 AM


At Toyota factories—yes, the car company—every assembly line has a big red button. And every worker has a responsibility to press the button if they feel something is amiss. This button stops the entire assembly line. Stopping the line could mean the difference between building a safe car versus building one that puts people at risk.

What does auto manufacturing have to do with healthcare? Everything, it turns out. At its core, this “stop the line” philosophy is about quality and safety. Just like Toyota factory workers, healthcare professionals operate in complex technical environments where mistakes can—and do—have grave impacts.

A 2018 John Hopkins study *1 found that up to 250,000 patients in the United States die annually from medical errors. This makes medical errors the third leading cause of death, after heart disease and cancer. If healthcare professionals “stopped the line” by speaking up when they have safety concerns, they could save patients’ lives. Yet as any healthcare professional knows, speaking up can be surprisingly difficult.

In 2013, at a University of California, San Francisco (UCSF) hospital, a young nurse was assigned to give a pediatric patient an alarmingly high medication dose *2. The nurse, Brooke Levitt, felt uneasy. But she rationalized it to herself. Perhaps the medication was diluted, or perhaps the patient was part of a clinical trial. She gave the patient his medication.

Brooke’s gut instinct was right: The dosage was 38.5 times higher than it should have been. Although the patient was ultimately fine, he suffered a grand mal seizure as a result.

UCSF investigated. One of the issues the investigation revealed? Brooke had not felt empowered to voice her concerns. She was a rushed recent graduate, unsure of herself and worried about bothering her busy colleagues. And this is not a unique phenomena. Many nursing professionals will relate to Brooke’s story. A nurse may sense something is off, but hesitate to speak up.

As frontline professionals, nurses are uniquely poised to prevent medical errors. Yet too often, they feel stuck between a rock and a hard place, helpless to step in when something is wrong.

The key is empowering nurses to stop the line. It takes courage to intervene when a surgeon is rushing through a safety checklist, or when a medical student is improperly inserting a central line catheter.

Of course, the rest of the team has to be willing to listen. For stopping the line to be successful, the organization’s culture must support it. This often requires serious effort. If you are a leader in a healthcare environment, consider establishing procedures around stopping the line. If you are a nursing professional, think about how you can integrate stopping the line into your own work. You owe it to your patients and colleagues to speak up. Your voice helps protect everyone.

What language should healthcare professionals use when stopping the line? Many organizations use the acronym CUS: concerned, uncomfortable, and stop *3. This language gives nurses a way to state the degree of their concerns. Some organizations use the phrase “I need some clarity,” as a way to signal the team to stop and assess safety concerns *4.

When will you stop the line? Try to come up with three scenarios where you would stop the line, or would want your employees to stop the line. Examples might be beginning a procedure on the wrong site, or administering medication without checking patient ID.

If a safety concern is discovered, what will you do to prevent this from happening again? Hospital leadership needs to understand what caused the issue on a structural level. Perhaps pharmacists are being interrupted while labelling medications, causing them to lose focus. Perhaps certain units are frequently understaffed and thus, rushed. Once the root cause is discovered, steps must be taken to resolve it and ensure patient safety going forward.

What happens if someone stops the line, but there was no safety concern? Inevitably, sometimes the stop will have been unnecessary—perhaps an unusual medication dosage is actually the correct one. Even in these cases, the decision must be supported. People will not stop the line if they worry they will be penalized for making the wrong call. As a nurse, encourage yourself to err on the side of safety. As a leader, encourage the same in your team.



1 https://www.cnbc.com/2018/02/22/medical-errors-third-leading-cause-of-death-in-america.html

2 https://www.wired.com/2015/03/how-technology-led-a-hospital-to-give-a-patient-38-times-his-dosage

3 http://www.pressganey.com/docs/default-source/industry-edge/issue-11---december/is-it-in-you-to-stop-the-line-for-safer-care.pdf?sfvrsn=2

4 https://www.leanblog.org/2009/03/stop-line-in-hospital

Topics: safety, patient safety, mistakes, stopping the line, prevention

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