A relentless pursuit of patient safety

Naomi Coates, left, and Kelly Chiles.

The health care industry in the U.S. is extremely fast-paced and complex, which makes the delivery of health care prone to error. In fact, medical errors are believed to result in as many as 440,000 preventable deaths every year in the U.S., making it the third leading cause of death in this country.

When patients come to Michigan Medicine, they trust that the world-class faculty and staff in our health system will efficiently address their health care needs and keep them safe from harm. Unfortunately, systems sometimes fail, and harm can reach patients. Improving these systems is part of the work the organization has begun on its journey to high reliability.

Thankfully, Michigan Medicine has faculty and staff who speak up in a relentless pursuit of safety, like Kelly Chiles, R.N., a nurse in the Frankel Cardiovascular Center (CVC) operating rooms, and Naomi Coates, B.S.N., R.N., a CVC operating room nursing supervisor.

A difficult procedure

Chiles and Coates were both on duty in the CVC operating rooms (OR) one morning, following a particularly challenging surgical case that finished late the night before.

A patient had been transferred to Michigan Medicine from another institution for coronary artery bypass surgery. The patient also had diabetes and was on dialysis because his kidneys were not working well. Due to these health conditions, the patient’s heart was enlarged, making it harder to perform the operation.

After several hours in the OR, the surgical team successfully completed the difficult procedure and ran through the standard post-operative checklist. While completing the checklist the team noticed a surgical sponge was missing. Sponges are used during procedures to absorb blood and other bodily fluids around the surgical site, helping the surgeon better see the operating area.

The team conducted a secondary check and followed necessary procedures to search for the missing sponge. While the team searched the OR, the surgeon ordered a chest x-ray to see if the sponge could be located in the patient’s chest cavity. The x-ray was read negatively, indicating that the sponge was not in the patient, and because of clinical concerns regarding lifting the patient’s heart which might endanger the recently placed grafts and induce an irregular heart rhythm, the team elected to move him from the OR to the ICU.

The following morning, the sponge had still not been located so at shift change, the night nurse included the missing sponge in her information transfer to the day nurse, Chiles.

“I was in charge that day so when I came in, I debriefed with the night nurse and she informed me that the surgical team filed a report for a missing sponge so I was immediately on alert for that patient,” said Chiles. “I pulled up the chest x-ray taken the night before and reviewed it with Naomi as soon as we could. I just had a gut instinct that something wasn’t right because the surgical team had been unable to locate the missing sponge the night before.”

Together, Chiles and Coates decided to get to the bottom of it.

Relentlessly pursuing safety

After reviewing x-rays taken after the surgery, Chiles and Coates decided to escalate their concerns to the physician assistant on the floor because he had been in the surgery the night before and had an immediate tie to the case.

“I am not a radiologist but I felt like I saw something in the x-ray films that needed to be further reviewed,” said Coates. “We talked with Alex [the physician assistant] and decided to order another x-ray to see if we could get a better picture.”

Over the next day, two additional x-rays were ordered and radiologists again concluded that the images did not show a sponge inside the patient’s chest cavity.

“We took more x-rays and the conclusion kept turning out the same, but we kept pursuing it because we knew the radiologist was not specifically looking for a retained sponge and therefore may not see the images the same way we were,” said Chiles. “We finally succeeded in getting an x-ray ordered specifically for the purposes of ruling out a retained sponge, and the faculty member from radiology who reviewed those films reached the same conclusion we had.”

Once the team received confirmation from radiology, the patient and his family were informed of the retained sponge, and he was brought back to the operating room where the surgeon successfully located and removed the sponge.

Speaking up for safety

Both Coates and Chiles are thankful for the support they received from colleagues.

“I never felt like I was going to be punished or get in trouble for speaking up and questioning the missing sponge,” said Coates. “Kelly and I view our job as being an advocate for our patients, and that is exactly what we were doing in this case. I think it is important for us to speak up for safety.”

Chiles agreed and added that she hopes others will learn from this experience.

“Nothing bad ever happened to us because we spoke up about what our gut was telling us,” said Chiles. “People asked questions but never questioned us, and it never turned into a situation where anyone was trying to blame someone else. We all wanted what was best for the patient and worked together to fix the problem.”

Speaking up for safety is a key component of the work Michigan Medicine has started with Healthcare Performance Improvement (HPI), an outside consulting group, as part of a journey to a robust safety culture and high reliability.

“This case is a great example of the culture we are working to build through our partnership with HPI,” said Devin Carr, D.P.N., R.N., chief nursing officer for UH/CVC. “I personally want to thank Kelly and Naomi for their relentless pursuit of safety and hope that we can all learn from their experience about the importance of speaking up for safety.”

Following this event, the Office of Patient Safety led a full multidisciplinary review to determine a root cause and identify process improvements that can be implemented to address the system gaps that contributed to the case.

“Naomi and Kelly ultimately persevered in their pursuit of safety, but it is our job as an organization to improve the system so faculty and staff have confidence that following procedures will keep patients safe,” said Carr.

As Michigan Medicine advances on the journey to high reliability, work will continue to improve systems and processes in an effort to provide patients with the highest quality and safest care. To read more about the journey to high reliability, click here.