Our APSS outline actionable steps healthcare organizations should take to successfully implement and sustain behavior change for high reliability, shared understanding, thorough communication, and meaningful person-centered care across the organization.
Actionable steps include:
Executive Summary Checklist
Leadership checklist guide to determine whether current evidence-based guidelines are being followed in your organization
Performance improvement plan to follow if improvements are necessary
Clinical workflow for preoccupation with workflow for areas of improvement
How to educate patients and family members about the significance of their role throughout the continuum
Guidance on how to measure outcomes
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APSS are revised annually and available free of charge on our website for download.
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Each APSS is developed by a multidisciplinary workgroup comprised of patient safety experts, healthcare technology professionals, hospital leaders, and patient advocates. The Foundation is proud to connect as many stakeholders as possible to focus on how these challenges can best be addressed.
We believe that progress cannot be achieved by sitting on the sidelines; we must take ACTION together. Like-minded individuals are the driving force that makes our mission to reach ZERO preventable deaths not just conceivable, but achievable.
At the time, I was working in the information services department at our local hospital. I was still at work when one of Drew’s older brothers called to tell me Drew had an accident on his skateboard. Drew grew up skateboarding around the neighborhood with his friends. They would go from house to house and skateboarding was how they got around. This night Drew lost control coming down a hill and fell backwards striking his head on the pavement. My wife and son were at the scene in less than 5 minutes while I was talking to them on the phone and I began walking over to our emergency department. Drew was talking to my wife the entire time and she rode in the ambulance with Drew to the hospital. I began to feel better knowing he was communicating with her.
As soon as I walked into the emergency department I told them that my son Drew was on the way and I wanted him transferred to Vidant Medical Center in Greenville, NC as soon as arrangements could be made. I wanted him evaluated by a specialist that wasn’t available at our hospital. I wasn’t sure how severe Drew’s injury was, but I didn’t want to wait until he got there to start working on transferring him. I wanted the transport to be established, so as soon as Drew arrived, there would be no delay in getting him to a hospital that could handle any situation that may come up.
When they arrived at the hospital I was by my son’s side the entire time until they prepared him for transport to Vidant. Drew has two older brothers, both of whom have had concussions. As a retired NC State Trooper and with experiences with my older sons, within minutes of talking to Drew I became less and less concerned. My oldest son had a worse concussion his senior year playing football than Drew appeared to have. I went into the room with him when they performed his CT scan a little over an hour after the accident. Everything came back normal with the exception of “a small amount of gas seen within the right temporal and mandibular joints”, and though none was seen, they suspected a possible basilar skull fracture. Drew was very aware of what was going on.
At one point during the CT scan I needed to remove Drew’s shorts. Drew immediately told me “#$%^ no, you’re not taking off my shorts in front of everyone” and I told him that I would leave on his boxers. The staff behind the glass got a good laugh out of this and I even laughed a bit. Drew knew what was going on. It was at this time that he looked me in the eyes and said, “Dad, I’m scared” to which I replied “You’re going to be OK” and I believed that with all my heart! I know my son as every parent knows their children and I knew he was OK.
Drew was the finishing piece to the puzzle that was our family. He was always happy and brought a balance to our home that was perfect.
We then went back to the ED where, after some time, they arranged to transport Drew via the hospital’s EMS service. Vidant was unable to pick up my son that night due to bad weather conditions. The only crew working that night was on the way back from Greenville so the hospital had to find a driver and paramedic to start the trip until we could meet the ambulance on the way back and change personnel.
They got a respiratory therapist(RT) and a nurse to ride in the back as well. It was at this time that I was told that they wanted to intubate him, as a precaution, for his safety. I didn’t understand why, he was breathing on his own, but I got the impression I didn’t have a choice and I needed to just trust that the staff knew what they were doing. Drew was a strong kid and we weren’t going to be able to ride in the ambulance with him.
I think they were nervous about making the one and a half hour trip to Greenville. The worse thing that would happen is he would sleep during the trip to Greenville and everything would be OK. As I walked out of the room I said “I love you” to which Drew replied “I love you too, Dad”. Not long after intubating him the first time, while still in the ED, Drew woke up and pulled out the tube. This made me nervous. He had not been sedated enough and Drew had the same reaction anyone would have if you woke up and had a tube in your airway. They sedated him further and prepared him for transport.
At no time did I fear for his life. My wife came up to me and wanted to kiss him bye and I told her, “you can kiss him when we get to Greenville, he’s fine”. I wanted to get in the car so we could follow them to Greenville. I’m so sorry to my wife for that. Hindsight is 20/20 but at two and a half hours after the accident I knew he was going to be fine.
We left the hospital following the ambulance in our car. We were about five minutes into the trip when we had to stop to meet the ambulance heading back from Greenville to change paramedics. Once that was done we were en route again. A few minutes after the transfer of personnel the ambulance suddenly pulled over. The paramedic driving the ambulance got out and got in back of the ambulance. My wife saw that Drew had sat up on the stretcher.
What we found out from the records was that Drew had woken up again and had pulled out the breathing tube again. He was aware enough to grab the arm of the paramedic to prevent her from giving him, what would turn out to be Vecuronium and he tried to bite the finger of the RT who was trying to keep him from removing his breathing tube. Drew was scared and was fighting for his life!
He woke up in the back of an ambulance, gagging on a tube, with people he didn’t know. None of the crew on board had the training or the experience to handle this situation. AT 3 hours after the accident Drew is aware of what he is doing and breathing on his own; that is, until one of the paramedics administered a paralytic that kept him from moving or breathing on his own in order to control Drew. During this time, 10 minutes that seemed like forever, we were sitting behind the ambulance in our car wondering what was going on.
I got out and knocked on the window to the ambulance and the nurse on board gave me a thumbs up. The thought of Drew being paralyzed and awake is a thought I have a hard time dealing with. I was sitting right behind the ambulance and my son, who had no doubt I would always protect him, was having his life taken away and I did nothing to help him. That was my job! The ambulance started back to Vidant and we then proceeded on towards Vidant completely unaware of what was going on. We were stopped by a State Trooper, who I don’t know, but I believe God put him there so the ambulance would go on ahead and we wouldn’t see what happened next.
When the respiratory therapist reintubated Drew (placed the breathing tube back in) the tube was placed incorrectly and was not in his airway. At the time this particular respiratory therapist had been licensed less than a year. Many of you may know, but if you don’t, a Respiratory Therapist’s job is airway management.
This means the RT’s job, and what she was trained to do, was to make sure Drew was breathing properly. His oxygen level was dropping and his heart rate was slowing. The ED Doctor’s notes state, “Staff called in- pt dislodged tube and may have aspirated. Pt reintubated but O2 sats low.” (This means his oxygen level was dropping) The ED Doctor added an addendum to her original notes stating that she informed the crew on the ambulance to “recheck tube and suction because arrest may be more respiratory related at this time.” Due to lack of oxygen Drew’s heart stopped beating and CPR was initiated.
The transport notes from the ambulance state that they pulled over at 11:15. At 11:17 Drew was given Vecuronium, the paralytic, which acts very quickly. It is important to note that after administering the paralytic and before they reinserted the breathing tube they were “bagging” Drew. Using a facemask and bag you manually compress, forcing air into his lungs similar to how you would during CPR. It is also important to note that Drew was awake! During this time his oxygen level remained in the upper 90’s, where it should be. At 11:20 they reintubated Drew. At 11:21 his oxygen level had dropped to 86%. AT 11:23 Drew’s oxygen level had dropped to 40%. At this point anyone with the correct training and experience would have noticed that the ETT tube was probably inserted incorrectly, but they never removed the tube. His heart rate had dropped into the 30’s at 11:25pm with no palpable pulse.
Drew went without Oxygen for over 30 minutes because they intubated him improperly. Even though required by the State of North Carolina, the monitoring (capnography) equipment required to be used for this type of intubation was not used. Even though Drew’s oxygen level began to drop almost immediately after reintubating him and they had orders from the ED Dr. to do so, they never attempted to reintubate him or correct his airway.
When the ambulance diverted to a closer hospital to stabilize Drew, the staff there quickly recognized the improper intubation and was able to correct the mistake that was made, but the damage was done. They had drawn Drew’s blood and found that Drew had a blood gas CO2 level of 88.7 and a ph of 6.8. Drew was aware at 3+ hours after the accident but when he arrived at Vidant Medical Center he had no brain activity. All Vidant could do for Drew was act on what they received not fully knowing what happened to Drew in the ambulance.
The Do It For Drew Foundation wants to help prevent what happened to Drew from happening to anyone else.
We feel passionately that with Drew’s story we can bring awareness and education regarding emergency care to medical professionals all over the country. What happened to Drew was completely preventable and no other family should have to go through what we have had to endure.
Weather, as well as other variables, often affects the ability of larger hospitals to pick up patients which means that the transferring hospital will transport the patient. Communities should feel confident in their local hospitals and, if the need to be transferred arises, we should feel confident in the people performing the transport of our loved ones. We also want to ensure that the state agencies overseeing these emergency medical professionals hold their members accountable and strictly enforce the rules and requirements that are in place to prevent this type of event from happening. This is a problem in many areas, but we feel this is something that can be corrected. We are just starting to scratch the surface of what we would like to accomplish, but coming soon, and over the coming years, we think wonderful changes can be made that will prevent serious injury to, or loss of life of, people in our community, state, and beyond.
On Sept 21, 2013 we and others were involved in a serious boating accident in which Jennifer sustained multiple internal life-threatening injuries, including several broken bones, head and neck trauma, and external lacerations. She was airlifted to a Level 1 Trauma Center and underwent multiple emergency surgeries.
She remained in a medically-induced coma and on life support systems for the next three weeks. In addition to her recovery from the injuries, Jennifer had to battle hospital-acquired conditions including VAP (Ventilator Associated Pneumonia), a UTI (Urinary Tract Infection), and BSI (Blood Stream Infection) before she regained consciousness and was able to breathe on her own through a trach airway.
After a total of four weeks stay in the Trauma Unit, she was discharged to an LTAC (Long Term Acute Care) facility. Soon thereafter, additional complications showed up including surgical site infection at the trach and a Peg Port infection in the abdomen. After three nights at the LTAC facility, Jennifer had to be admitted back into a Community Hospital for treatment of these newly acquired complications.
After two weeks at this hospital, her condition had significantly improved to where she had become mobile, was disconnected from most all tubes and lines, was able to go to the bathroom on her own, and was looking forward to eating soft foods again. At this time, she was breathing on her own, however, still with assistance through the trach port. Discharge planning had begun and we were told that by Wednesday morning she would be going home and would receive physical rehabilitation assistance. We really thought we had climbed a huge mountain and were now homeward bound.
A final requirement in support of the discharge and to starting on soft foods was that Jennifer needed to pass a barium swallow test.
Early Monday morning during this swallow test it was discovered that Jennifer had a TEF (tracheoesophageal fistula), which is a hole in the tissues between the trach and the esophagus. This a very serious complication and it requires a complex surgery to repair. This discovery triggered a series of intervening events, or at least we assumed so.
First and foremost, as a result of the barium migrating into her lungs, this brought about a high degree of respiratory distress. Over the next 36 hours, Jennifer was bounced and transferred back and forth between multiple units and caregivers. Her respiratory distress was also misdiagnosed as anxiety and thus multiple doses of Ativan were administered, further complicating the situation.
As the distress continued to progress, it ultimately landed Jennifer back in the ICU on Tuesday afternoon. There were no rooms available at this time, so they placed her in a recovery area, at which time the decision was also made to place her back on a ventilator.
Sadly, the caregivers at the time were unaware of the recently diagnosed TEF and they simply began ventilation through the existing trach. For the next 6 hours, they increased the cycle rate and O2 concentration levels until they were at 40 cycles per minute and 100% oxygen. No physical assessment was made, no blood gases were taken, and no ETCO2 monitoring occurred. All the while, the air being pumped into Jennifer was not going to her lungs, but instead escaping and collecting into her abdomen via the TEF.
At 12:04 AM, her body and organs had become completely oxygen deprived and Jennifer went into full cardiac arrest. A code blue was called and CPR was administered for 14 minutes, finally resulting in a restored heartbeat.
Needless to say, her brain had been so severely deprived of oxygen and glucose during this extended period of time that an unrecoverable amount of damage had occurred. The code blue team discovered Jennifer’s belly had been extended to 4X normal size, They did an emergency pressure relief through her abdomen and then re-intubated her, removing the trach and then using a longer ET tube where they isolated the TEF from the lungs.
For the next three weeks, Jennifer was kept alive on life support while remaining in a totally non-responsive state, during which time countless tests, scans, and neurological consults were conducted, all of which pointed to the same conclusion: massive and non-recoverable brain damage.
On November 19th, the decision was made to discontinue life support as there was no hope of reversing or recovering from the complexity and tragedy of these multiple medical communication hand-off errors and acquired complications. To this day, over two years later, not a single person at the hospital has ever said a word to me about the death of my beautiful wife.
Oddly, Blue Cross/Blue Shield (the member Health Plan) paid everyone involved in full, to the tune of $2.1M in submitted medical bills. BC/BS did not even know that Jennifer had passed away from these errors until I contacted them 1.5 years after the fact. And we all wonder why these types of patient safety tragedy stories continue to occur year, after year, after year. It’s really not hard to understand…to say that the system is broken is a gross understatement.
In the fall of 2013, my husband Dave Bunoski and I were spending the weekend at our cottage on Maryland’s Eastern Shore. We had purchased the weekend home six months prior and we were in love with our little slice of the pie.
We’d attended a large oyster festival with out of town friends on Saturday. We were excited to share our home with friends that weekend, it was a beautiful day and we had a wonderful time.
On Sunday morning, we woke up to a gloomy, damp morning. We decided to lay low that day, and have some new local friends over for dinner later. I went to the store and when I returned, Dave met me at the door and said: “Don’t get alarmed, but I called an ambulance.” He told me he was having trouble breathing, but he still had the presence of mind to tell me to lock our dog in a back room so he wouldn’t be in the way of the paramedics.
When the paramedics arrived, they took Dave’s vitals, gave him oxygen, and asked him questions about his health history. Dave was able to provide answers, but I could see he was becoming more and more agitated about his breathing. They decided to transport him to the local hospital and he walked to the ambulance with little assistance. I asked if I should join him or drive on my own and he said, no, take the car, we’re going to need it when we come home. Then he headed back to the ambulance. I still have the scene in my head. I was standing on our porch. He stopped again, turned around, and told me he loved me.
Our cottage is located in what is considered a rural area and the closest hospital was 12 miles away. We actually considered the location of the closest hospital when we bought the house and agreed that the town had a strong volunteer fire department and paramedic program. In fact, at the oyster fest the day before, I tipped the volunteer fire department team well at their tent and said: “We’re going to need you some day.” Little did I know that in less than 24 hours that statement would be true.
After the ambulance pulled off, I needed to get the dog, and I asked our neighbors to keep an eye on him for a few hours while we were gone. We were new to this area and had just met these neighbors, who graciously helped us out. By the time I left, I was about 15 minutes behind the ambulance.
When I arrived at the hospital, Dave was not there, nor did they know where he was. I called the fire department and was told that he was diverted and was in another hospital – in another state. Apparently, he stopped breathing on the way to the local hospital. The paramedic attempted to intubate Dave, but instead of placing the tube in his trachea or lungs, it went into his esophagus. They made multiple attempts with the tube and then made the decision to reroute to a tertiary hospital.
By the time I found where they had taken him, two to three hours had gone by. When I arrived, Dave was in a coma and on life-support.
Since I was not with him in the ambulance, I had no idea what had happened and was basing decisions on speculation and quite frankly, hope.
This began the inside the hospital journey.
Due to his condition, Dave was seen by many specialists. He had a cardiologist, neurologist, pulmonologist, and several hospitalists over time. Each focused on their particular specialty, or as I called it, Dave’s “parts” and nobody looked at him as a whole and real person.
The cardiologist would come in and say his heart looks great, followed by the pulmonologist who would tell me his lungs look great. When the neurologist would come in, he would say, too early to know the level of brain injury. I would look at them all and say this is all good news, but he is still in a coma?
I asked all the pointed questions. “How long was he without oxygen?” and “How long could he be without oxygen and still have a quality of life?” After we decided to try to see if Dave could breathe on his own through a tracheotomy, and put in a feeding tube, we had some answers. After several weeks, we learned how long he was without oxygen between the attempts to intubate him in the ambulance. We had access to the report and could piece together a timeline.
Dave was without oxygen for 15 minutes. Had I known that early on, I would never have subjected him to the tracheotomy or the feeding tube. I knew the man he was at the oyster fest that sunny day was gone.
There were several errors that happened across systems that resulted in our loss. We have since learned how difficult intubation can be, in particular while in a moving vehicle. We also know there are evidence-based models that can reduce error in intubation that are not widely utilized.
The coordination and communication across systems and between providers has to be improved. From the transition between our home and the hospital to communications between the providers in the hospital and the paramedics and the providers, it all resulted in poor decisions being made and a lack of family engagement.
Dave had two deaths. The first was in the ambulance. The second was six weeks later. We know the first could have potentially been avoided. If that was not to be the case, we know the other could.