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Quality Improvement & Patient Safety Section Newsletter - March 2009, Vol 10, #2

Quality Improvement & Patient Safety Section

circle_arrow The Chair’s Corner
circle_arrow Editor’s Note
circle_arrow Handoffs Grant
circle_arrow Labeling of Syringes and Containers on Sterile Field
circle_arrow Rapid Response System (Aka MET: Medical Emergency Team) Development
circle_arrow QIPS Tips
circle_arrow I’m a Structure Guy
circle_arrow ACEP Quality and Performance Summit

Newsletter Index

Quality Improvement & Patient Safety Section



The Chair’s Corner

Robert I. Broida, MD, FACEP

broidaThere has been much activity in the QIPS Section lately. Two major projects are coming to fruition and we are looking to obtain funding for two more! 


  1. Quality Curriculum Grant: This project team, headed by Jack Kelly, MD, FACEP (Albert Einstein Medical Center, Philadelphia) has created a master curriculum focused on quality in emergency medicine. This will allow program directors and faculty to easily prepare residency content using selected references deemed by the project team to be the best available. When completed, the goal is publication in Annals. Co-editor is Elaine Thallner, MD (Cleveland Clinic).

  2. Hand-Off Grant: Dickson Cheung, MD, MBA, MPH, FACEP (Sky Ridge Medical Center, Lone Tree, CO) is heading this project, which is producing a White Paper on the current state of the art in ED transitions of care between providers, as well as looking at best practices and goals for future study. Directly addressing the Joint Commission National Patient Safety Goal (#2E), this project team has over 30 active participants and is currently finalizing the White Paper for submission to Annals. Jack Kelly is co-editor.


  1. Drew Fuller, MD, MPH (Johns Hopkins) and Jack Kelly have proposed a new Section Grant on Hand Hygiene in the ED, based on their own experience (and challenges) with implementing handwashing programs. This is on the Joint Commission radar screen, as it is a National Patient Safety Goal (#7A). The Section leadership believes that this project will be of great benefit to the membership as a whole, since each hospital will need to address the issue.

  2. Mike Phelan, MD, FACEP (Cleveland Clinic) has submitted a Section Grant entitled "Confirmation of Endotracheal Tube Placement Online Educational Program." The objective is to develop an online CME program based on the ACEP Verification of Endotracheal Tube Placement Clinical Policy. Having an easily accessible online CME tool near the online policy statement will allow ACEP members an opportunity to earn CME while providing greater exposure to the clinical policy. If successful, this approach could be used for other clinical policies.  

Action Items:  

  1. Survey: We need your vote! Our first interactive QIPS Survey is published below (click here).
  2. QIPS Membership: Please think of 1-2 of your colleagues that might be interested in joining QIPS. Email them this link ( ) and encourage them to join!
  3. Request for Authors: QIPS needs articles for our next newsletter. Please address submissions to Drew Fuller ( 

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Editor’s Note

Drew Fuller, MD, MPH

Drew Fuller
As we enter into a new year, we have continued to refine the content and structure of the newsletter with the aim of keeping our members up-to-date on the section’s activities as well as providing useful0309EditorsNote insights and information for improving quality and patient safety in our nation’s emergency departments.

In this quarter’s newsletter you will find two new sections. First is our QIPS TIPS section. This will become a regular section feature and will be comprised of brief helpful insights and pieces that can be use by practicing emergency physicians and ED administrators. This month will kick off with Shari Welch and promise to bring more of her pieces in future editions. If you have a QIPS TIP to share, please forward it to me (500 words or less) to  

Our other new addition to the newsletter includes the instant feedback survey question. Learn how others around the country answer in 5 seconds.  

Our current question is on hand washing.  

Have a question idea? Send to us (  

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Handoffs Grant

Dickson Cheung, MD, MBA, MPH, FACEP 

Dr. Dickson CheungBy the time you receive this newsletter, we should be in the final month of the handoff grant project. We have about 15-20 members that have continued to contribute in an ongoing effort to better understand and improve handoffs. Personally, it has been a very gratifying collegial effort. The dedication of the grant team over the past six months has been inspiring.

The main topics of discussion have been centered on the advantages and pitfalls of standardization of handoffs, the appropriate use of bedside rounding and the barriers preventing good handoffs. In the end, we propose about 16 suggestions for improved handoffs. Although we have not reached complete consensus yet, it is startling how a large group which divergent opinions begins to converge after six months of conversations and emails.

The final products will include a white paper, a publishable concept paper and a slide set for educational efforts in grand rounds and other teaching venues. The first draft of the white paper was completed in early February. It is about 20 pages with complete references. Another draft will be sent out by mid March. The paper will then be reviewed by three retained national experts on communication at shift change. By the end of April, we will have the final draft of the white paper for submission to ACEP. And hopefully shortly after, a paper submitted to Annals for publication. If you'd like a copy of the present draft and/or provide input on the final product, feel free to email me at

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Labeling of Syringes and Containers on Sterile Field

Helmut Meisl, MD, FACEP

meislThis somewhat difficult Patient Safety Goal has been out for some years and has been recently revised. I give you the latest Joint Commission wording, and my comments following, though do not claim to have the official answer. 




Joint Commission: National Patient Safety Goals
Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field.

Rationale for NPSG.03.04.01
Medications or other solutions in unlabeled containers are unidentifiable. Errors, sometimes tragic, have resulted from medications and other solutions removed from their original containers and placed into unlabeled containers. This unsafe practice neglects basic principles of medication management safety yet has been routine in many organizations.

The labeling of all medications, medication containers, and solutions is a risk reduction activity consistent with safe medication practices.

This practice addresses a recognized risk point in the safe administration of medications in perioperative and other procedural settings.

Elements of Performance for NPSG.03.04.01

  1. Medications and solutions both on and off the sterile field are labeled even if there is only one medication being used.
  2. Labeling occurs when any medication or solution is transferred from the original packaging to another container.
  3. Medication or solution labels include the medication name, strength, amount (if not apparent from the container), expiration date when not used within 24 hours, and expiration time when expiration occurs in less than 24 hours.
  4. All medication or solution labels are verified both verbally and visually by two qualified individuals whenever the person preparing the medication or solution is not the person who will be administering it.
  5. No more than one medication or solution is labeled at one time.
  6. Any medications or solutions found unlabeled are immediately discarded.
  7. All original containers from medications or solutions remain available for reference in the perioperative or procedural area until the conclusion of the procedure.
  8. All labeled containers on the sterile field are discarded at the conclusion of the procedure.
  9. At shift change or break relief, all medications and solutions both on and off the sterile field and their labels are reviewed by entering and exiting personnel.

This measure was generally designed for the operating room environment, where multiple solutions are used over a lengthy procedure, some of which can be toxic. However in the ED, we generally have short procedures, such as suturing and this labeling can be difficult and truly slow the process of ED flow. Possibilities to comply with this requirement would be to have a sterile marker to label all the syringes and containers, or to have pre-printed labels to attach to the containers at the time of use. However both of these are time-consuming. The Joint Commission does not allow pre-marked or engraved containers, as there may be confusion as to another medication being put in the designated container. In the past there was an exception, that if only one medication or solution was used, then there would be no confusion. However this no longer applies.

A possible solution to compliance would be to draw up or pour each medication (usually a local anesthetic) or solution (usually normal saline) and then immediately use it and then discard it off the peri-operative field. The question of compliance is "immediately". Does this word allow us to use the saline for a few minutes to irrigate the wound? This may be open to interpretation by each individual Joint Commission reviewer.

From my personal point of view, I do not believe that ED’s will have the time to label the containers and syringes all the time, but the immediate use and discarding hopefully would show to the Commission that the ED is addressing the safety intent in a realistic and practical manner. A sterile safety pen could be available in the department or on the tray if a solution or medication is used for a more prolonged time.

I and others in the Section welcome your thoughts on this area, and do send them in to me ( or to the Section List (

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Rapid Response System (Aka MET: Medical Emergency Team) Development

Elaine Thallner, MD, MS, FACEP
Director of Operations, Medical Response Team
Cleveland Clinic Foundation

thallnerCleveland Clinic is a 1400 bed tertiary care hospital that has instituted an in-house rapid response team process composed of three separate teams: one for pediatrics (led by PICU staff), one for cardiac patients (led by cardiothoracic anesthesia), and one for adult patients that is led by emergency medicine. The team is composed of an emergency medicine staff physician, an emergency registered nurse, and an emergency department respiratory therapist. Our team does not have emergency department assignments while on duty for the medical response team. The team carries a medication bag, central line equipment, intubation and other respiratory equipment, and is able to perform bedside point-of-care labs. The goal is to provide a ‘rescue’ process for patients experiencing warning signs that something is awry and to empower the nursing staff to bypass medicine’s traditional hierarchy. Nonpunitive, nonjudgmental, respectful interactions are expected. The team is usually activated by a nurse, although with increasing frequency, the patient’s primary team resident is also activating a MET (now about 15%). Approximately 65% of the calls are respiratory related, and endotracheal intubation is performed during approximately 20% of the calls. Over one half are transferred immediately to an ICU. Occasionally, a patient is sent immediately to the operating room or to the cath lab. Preliminary data indicate that as the number of MET calls has increased, the number of codes has decreased.  

As expected with change, there was initially strong physician resistance to participate on the team. Presently, the team is staffed only by those physicians who desire to participate and there is robust competition to get on the schedule. The team appreciates the positive feedback they receive when they respond to calls, not only from the nursing staff, but also from physicians, patients, and their families.  

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Shari Welch, MD, FACEP

QIPS Tips 1. Misadventures with the Lab

Shari Welch According to the CDC a full third of ED patients will have some laboratory testing done as part of their ED visit. Though laboratory testing can cause waits and delays due to operational failures, few departments have worked to address these common failures in a systematic way. The more common failures relative to lab performance fall into the following categories and involve the ED/Lab interface:

  1. Unlabeled Specimens/Mislabeled Specimens
  2. Lost Specimens
  3. Contaminated specimens
  4. Collection Delays
  5. Delays in Results Review 

There are a number of key concepts which can be applied to improve lab functioning for the ED. First, lab operations must not function as they often do, by intuition. All work relative to lab testing must be clearly articulated and assigned. Who will draw, label, collect, send and track laboratory specimens? All steps must be monitored for process failures. What is a process failure for a troponin? More than fifteen minutes to be drawn? More than thirty minutes for results to be returned? Below are key concepts for reliable and efficient laboratory processes in the ED:

Efficient, Safe Lab Processes:
General Concepts

  • Every task requires clear ownership
  • Every process requires clear articulation
  • Every process should have a time limit
  • Every process should have a measurable failure rate
  • Limit the number of people in the process
  • Labels follow patients ? from patient to specimen
  • Use lean tools and look at process for streamlining
  • One lost or mislabeled specimen is a catastrophe!

Applying these general concepts should get you on the road to improvement in this area. According to VHA and the Abaris Group, consulting firms that focus on high performance in the ED, specific practices have been identified as best practices for lab operations. These practices are listed below: 

Best Practices: Lab

  • Point of Care Testing
  • Bar Coded Labeling
  • ED Based Lab Tech
  • Tube System
  • Lab Draw and IV Start Simultaneous
  • Color Coded ED Specimens
  • Cueing for Results

QIPS Tips 5. Lethal Injections

According to the IOM there are more than 100,000 deaths per year due to medical errors. Healthgrades estimates that the numbers are even higher! Four per cent of hospitalized patients suffer an adverse event which extrapolates to a million injuries a year! One fifth of these are medication errors.  

According to a number of international studies, we get it right in medicine only 80-90% of the time. What can be done in the emergency department to improve on these statistics? The first step is to recognize that humans do err, and they do so frequently, predictably and regularly. In the IOM report TO ERR IS HUMAN for the first time the profession acknowledged the limits of human performance. This is an important acknowledgement, for if we do not take note of this reality and build our work flow and processes to compensate for our errors, we will never manage them. On the other hand, by changing the culture to encourage the identification of errors and then adapting the system to compensate, we may eliminate many of the errors or at least compensate for them and mitigate the consequences.  

Potassium Chloride is one of the most dangerous drugs we carry in an emergency department. Numerous deaths have been reported due to accidental overdoses either by infusing too much too quickly due to incorrect preparation and calculation or by accidentally grabbing the vial in lieu of another medication. This error is fatal (remember we use this for lethal injection in capital punishment cases!) and many patient safety experts have come to feel this drug has no place in an ED where human error can lead to a fatality. Many health systems have taken it out of dispensing systems and med room altogether and have potassium drips pre-made in the pharmacy where standardization has lead to improved safety. Shouldn’t you set this up with your pharmacy, today?

Please share your safety or quality tips with your colleabues! Submit your tip to


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I’m a Structure Guy

Robert Broida, MD, FACEP

0309StructureGuy1We all went into medicine for different reasons, but a good many of us did so to help people. Quality care is something we believe in. But what is Quality today?   

People: Quality begins with us. Better educated, better trained, better credentialed clinicians can be reasonably expected to provide better care. This is one of the main reasons that ABEM was created ( and the mission for the state Boards of Medicine. Most residencies, ED groups and hospitals focus on this aspect of quality in their recruiting. But that’s just a start.

Clinical / Scientific: Compliance with established standards of clinical care (some of these are evidence-based) is also a reasonable standard for quality. This is what the government uses in order to determine public reporting of web-based quality scores (, et al) and increasingly, pay for performance reimbursement. The various "quality measures" which have been promulgated are easy to measure, easy to extract from electronic chart data, and have the tacit approval of various physician organizations, including ACEP.  

0309StructureGuy2Satisfaction: Quality, as determined by the end-user, frequently is based upon non-scientific, non-outcome-based criteria. Likeability, compassion and caring are essential components of a successful practitioner and to some extent, skills which can be learned. Hospitals have embraced this measure of quality in a big way and we have seen a variety of commercial satisfaction measures gain wide acceptance over the last decade (Press Ganey, Avatar, NRC Picker, et al). Many hospital CEOs have incentive pay which is based on these scores.

Process / Structure / Flow: We all have experienced varying degrees of frustration with the needlessly complex, bureaucratic nature of emergency medicine practice today. Anyone who has sat in an ED waiting room with a sick child or an elderly parent understands the major impact this has on their perception of quality. After a five-hour stay, an ED with the nicest, best credentialed, clinically competent physicians may be graded poorly by patients with regard to their perception of quality. We work within a "system," and that system affects the quality we deliver.  

Prolonged lab turnaround times, radiology preps, scheduling, over-reads, outdated physical plants, inadequate staffing levels and staff competencies, unavailable consultants, inadequate admission bed availability, etc. all lead to ED overcrowding, prolonged lengths of stay, increased LWOTs, AMAs, and staff and patient dissatisfaction. These are all hospital structure / process issues which affect the delivery of quality care and cannot be addressed by stellar credentials, scientific adherence or a happy smile. I’m a structure guy.  

0309StructureGuy3Inpatient bed availability / ED boarding is a significant problem, but it’s more than that. It’s the built-in bureaucratic inefficiencies that affect each and every patient, even when beds are available. Addressing the smaller issues which are more within the control of the ED can provide the momentum (and political capital) necessary to tackle the more thorny institution-wide problems.  

I challenge each of you to work with your hospital ED leaders to:  

  1. Measure your key ED processes (door to doctor, lab turnaround times, length of stay, etc.)
  2. Track these (at least monthly) and post in the ED for all to see.
  3. Form a workgroup to address improvements in each key area.
  4. Drill down to identify the major roadblocks.
  5. Focus on "curing" them one by one.
  6. Execute on the plan.  

This process will not occur without a champion. The ED is a complex system, with many moving parts. It takes a consistent approach in order to fix the many longstanding, interdepartmental hurdles to an efficient ED. Engaged emergency physicians can impact structural / process / flow issues in the ED and enhance quality of care, creating a healthier place for patients and a better place to work.  

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ACEP Quality and Performance Summit

Angela Franklin, Esq., Staff liaison

angelafranklinOn November 24, 2008, ACEP hosted a Quality and Performance Summit, which convened a group of thought leaders in the quality arena, including measure developers, physicians, hospitals, payers, and quality improvement entities.

The purpose of the day was to discuss quality improvement in the future, as quality initiatives have clearly begun to move into a new phase; and the potential roles, directions, for emergency medicine in working with all stakeholders.

High level speakers from the National Quality Forum (NQF), CMS, the AMA Physician Consortium for Performance Improvement, and other leaders in the quality movement discussed emerging national priorities related to physician value-based purchasing, public and private quality improvement initiatives, and concluded with a roundtable discussion covering ways that emergency medicine may be integrated into future public and private quality initiatives.  

Focus: Care Coordination

According to NQF Senior Vice President for Performance Measures Helen Burstin, MD, the group’s focus will likely turn to care coordination. She appealed to emergency physicians to think about their role in care coordination as well as the collective responsibility across all care settings. Well-coordinated care across all providers is a national goal, she said. Emergency physicians offer valuable input because they often sit at the nexus of the interface between the office-based physician practice and the hospital. Accordingly, ACEP is working on the NQF panel and participating in the concurrent AMA workgroup focusing on care coordination.

Please watch for another focus from the Summit in an upcoming issue. For additional information, please contact Angela Franklin at  

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This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.

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