See Primer. Rapid response teams represent an intuitively simple concept: when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to the bedside to immediately assess and treat the patient with the goal of preventing adverse clinical outcomes.
When information is conveyed verbally, miscommunication may occur in a variety of ways, especially when transmission may not occur clearly (e.g., by telephone or radio, or if communication occurs under stress). For names and numbers, the problem often is confusing the sound of one letter or number with another. To address this possibility, the military, civil aviation, and many high-risk industries use protocols for mandatory read-backs, in which the listener repeats the key information, so that the transmitter can confirm its correctness.
Because mistaken substitution or reversal of alphanumeric information is such a potential hazard, read-back protocols typically include the use of phonetic alphabets, such as the NATO system ("Alpha-Bravo-Charlie-Delta-Echo...X-ray-Yankee-Zulu") now familiar to many. In health care, traditionally, read-back has been mandatory only in the context of checking to ensure accurate identification of recipients of blood transfusions. However, there are many other circumstances in which health care teams could benefit from following such protocols, for example, when communicating key lab results or patient orders over the phone, and even when exchanging information in person (e.g., handoffs).
Rules that must be followed to the letter. In the language of non-health care industries, red rules "stop the line." In other words, any deviation from a red rule will bring work to a halt until compliance is achieved. Red rules, in addition to relating to important and risky processes, must also be simple and easy to remember.
An example of a red rule in health care might be the following: "No hospitalized patient can undergo a test of any kind, receive a medication or blood product, or undergo a procedure if they are not wearing an identification bracelet." The implication of designating this a red rule is that the moment a patient is identified as not meeting this condition, all activity must cease in order to verify the patient's identity and supply an identification band.
Health care organizations already have numerous rules and policies that call for strict adherence. The reason that some organizations are using red rules is that, unlike many standard rules, red rules will always be supported by the entire organization. In other words, when someone at the frontline calls for work to cease on the basis of a red rule, top management must always support this decision. Thus, when properly implemented, red rules should foster a culture of safety, as frontline workers will know that they can stop the line when they notice potential hazards, even when doing so may result in considerable inconvenience or be time consuming and costly, for their immediate supervisors or the organization as a whole.
See Primer. Efforts to engage patients in safety efforts have focused on three areas: enlisting patients in detecting adverse events, empowering patients to ensure safe care, and emphasizing patient involvement as a means of improving the culture of safety.
See Primer. Initially developed to analyze industrial accidents, root cause analysis is now widely deployed as an error analysis tool in health care. A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals.
Loosely defined or informal rule often arrived at through experience or trial and error (e.g., gastrointestinal complaints that wake patients up at night are unlikely to be functional). Heuristics provide cognitive shortcuts in the face of complex situations, and thus serve an important purpose. Unfortunately, they can also turn out to be wrong.
The phrase "rule of thumb" probably has it origin with trades such as carpentry in which skilled workers could use the length of their thumb (roughly one inch from knuckle to tip) rather than more precise measuring instruments and still produce excellent results. In other words, they measured not using a "rule of wood" (old-fashioned way of saying ruler), but by a "rule of thumb."
A type of statistical process control or quality control graph in which some observation (e.g., manufacturing defects or adverse outcomes) is plotted over time to see if there are "runs" of points above or below a center line, usually representing the average or median. In addition to the number of runs, the length of the runs conveys important information. For run charts with more than 20 useful observations, a run of 8 or more dots would count as a "shift" in the process of interest, suggesting some non-random variation. Other key tests applied to run charts include tests for "trends" (sequences of successive increases or decreases in the observation of interest) and "zigzags" (alternation in the direction—up or down—of the lines joining pairs of dots). If a non-random change for the better, or shift, occurs, it suggests that an intervention has succeeded. The expression "moving the dots" refers to this type of shift.