Health System Turns Safety Scare into Initiative to Improve Training on Complex Health Technology


Posted December 5, 2017

What clinicians don’t know about complex healthcare technology can hurt patients. Just ask leaders at Memorial Hermann Health System, located in southeast Texas, who were able to turn a scary lesson into a patient safety initiative that changed the way its staff looks at and are trained on complex medical devices.

Three representatives from Memorial Hermann shared their “fail safe” process during a patient safety seminar hosted by the AAMI Foundation in partnership with the National Association of Clinical Nurse Specialists on Dec. 4.

An ‘Alarming’ Incident

The journey toward eliminating patient harm due to a lack of knowledge about complex medical devices started more than five years ago when a ventilator in the one of Memorial Hermann’s intensive care units started to alarm, but the nurse could not figure out why.

“She went around the front; she went around the back … but she could not find the source or cause of the alarm,” explained M. Michael Shabot, executive vice president and system chief clinical officer for Memorial Hermann Health System.

A little while later, the patient coded. It turned out that the nurse had not been trained to use that particular ventilator, according to Shabot.

“If it was just the nurse, we could just let the nurse go and maybe that would solve the problem,” he said.

But the problem wasn’t the nurse; it was the system. At the time, Memorial Hermann lacked a standardized process to ensure “adequate and timely training” for clinicians and caregivers who used critical equipment, such as ventilators, leaving them—and their patients—vulnerable to the consequences of informal training.

“That’s when [we] realized that we needed to do something different with regard to ensuring training on our complex medical devices so that they would be safe to use. And that is really, in my view, the origin of the Fail Safe Program,” Shabot said.

‘Fail Safe’ Technology Use through Education

Following that incident, Memorial Hermann established an interdisciplinary Fail Safe Program team that spanned quality and safety, risk management, education management and specialists, clinicians, and the supply chain. The group worked to create a process that would ensure that new critical life safety and monitoring devices were not placed into service until the nurses and other caregivers who would use those devices received formal in-service training, and the training was documented, according Patricia Hercules, Memorial Hermann’s director of system clinical education.

According to the policy, devices categorized as “critical high risk” by the Fail Safe Steering Committee must have 100% documented compliance with individual caregiver education prior to being rolled out onto the unit. Those categorized as “complex medium risk” require 80% documented compliance.

The education plan, according to the presenters, is much bigger than a one-time lesson, and it may include information from the vendor, other online training modules, and/or hands-on skills training, followed by skill and knowledge validation through written, online, or oral quizzes and/or return demonstrations. All devices also must have support and resources available during “go live,” and critical high-risk devices require trained super users.

During phase one of the program (2012–2015), the Fail Safe Steering Committee assessed 83 medical devices, of which 39 (47%) were deemed “critical high risk.” In May 2016, the system began phasing in operating room (OR) and outpatient services. Since then, seven OR medical devices have been assessed as “critical.”

Building Best Practices

The AAMI Foundation launched its National Coalition to Promote the Safe Use of Complex Healthcare Technology earlier this year to build a repository of best practices that would address the challenges associated with introducing complex healthcare technology to clinicians.

“Although all of our patient safety initiatives to date have been challenging, this particular initiative will be even more so because it involves so many stakeholders inside and outside the walls of the hospital,” said Marilyn Neder Flack, senior vice president of patient safety initiatives and executive director of the AAMI Foundation. “However, all stakeholders must join this effort because as devices become increasingly complex, the probability that clinicians will lack some vital knowledge of when, why, or how to use these products with patients grows, and positive patient outcomes are at risk.”

Slides and a recording of this presentation are available for free from the AAMI Foundation’s website.