Error Prevention Toolkit

Everyone makes mistakes; however, when people in healthcare make mistakes, it can result in great inconvenience, harm or death. Although not everyone’s job at MLH has a direct impact on patients, we all make a contribution to the overall experience of patients, families, or visitors.

From 2006 – 2009, over 100 patient safety events resulting from not using safe practices were reviewed. The majority of errors related to breakdown in teamwork and communication (e.g., staff reluctant to speak up about risk or impending mistake; afraid to ask clarifying questions). Additionally, an MLH safety culture survey pointed out that 50% of the respondents were afraid to speak up to those in authority about things that could negatively impact patients.

Main Line Health is focused on creating a reliable culture of safety. Our mission is to provide a superior patient experience. Our goal is to be well ahead in patient safety by eliminating preventable harm. 

Use this Job Aid to understand your role in error prevention, and in achieving the MLH mission, goal and target.

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Our Safety Behaviors Error Prevention Tools
Attention to Detail

Self Checking Using STAR

STAR is a simple, 4 step technique for preventing skill‐based errors STAR is an acronym for
Stop: Pause for 1 to 2 seconds to focus attention on the task at hand
Think: Visualize the act and think about what is to be done
Act: Concentrate and perform the task
Review: Check for the desired result

The best times to use STAR are when you are going from thought to action, such as medication administration, entering data into a device or computer, sending an email with an attachment, or adding a value on a spreadsheet.

Communicate Clearly

3‐Way Repeat Back & Read Back

3 Way Repeat Back

  1. Sender initiates communication using receiver’s name.  Sender provides an order, request, or information to receiver in a clear, concise format.
  2. Receiver acknowledges receipt by a repeat‐back of the order, request, or information.
  3. Sender acknowledges the accuracy of the repeat‐back by saying,

“That’s correct!” or “No, that’s not correct.”  If not correct, sender repeats the communication.

3 Way Read Back 

  • The receiver writes the information, request or order and reads it back.
  • Don’t rely on your memory…write it down whenever you receive critical information that might be difficult to remember.

Communicate Clearly

Phonetic & Numeric Clarifications

Phonetic clarification is a good practice to use for sound alike words. When communicating verbally say the letter and follow it with a word that begins with the letter. It is critical that we use phonetic clarification when we are communicating important information.  It doesn’t matter whether your “D” is Duck, David, or Delta.  What’s important is that you use a phonetic clarifier.

Examples: A  =  Alpha, B  = Bravo, C  =  Charlie, D  =  Delta, E  =  Echo

Communicate Clearly

Clarifying Questions

This error prevention tool is used to ensure understanding, to make sure you really understand what’s being communicated, and so you don’t make a decision based on a wrong assumption. Use clarifying questions:

  • When in high risk situations
  • When info is incomplete
  • When info is not clear

Ask your question in a way that will give an answer that improves your understanding of the information.

Handoff Effectively

Use SBAR to Handoff

Use SBAR to  handoff when communicating about a problem or issue that needs resolution

Situation: Who / what you’re calling about, the immediate problem, your concerns
Background: Review of pertinent information: environment, procedures, employee status
Assessment: Your view of the situation or urgency of action: “I think the problem is…”,  “I’m not sure what the problem is…”, “The situation is deteriorating rapidly—we need to do something.”
Recommendation: Your suggestion or request to the other person

Speak up for Safety

Question & Confirm

Critical thinking requires a questioning attitude. People who lack critical thinking skills make errors because they:

  • Make wrong assumptions
  • Fail to note a condition that is unusual
  • Use information that is obviously incorrect
  • Misinterpret correct information

If something doesn’t seem right, it probably isn’t.  Ask yourself:  Does it make sense to me? Does it fit with what I know? Is it what I expected to see? To confirm, check with an independent or expert source (such as: policy, reference, medical record, manager)

Speak up for Safety

Use ARCC to escalate safety concerns

This error prevention tool is used to help escalate a concern in a non‐threatening way. ARCC helps to advance the concern if it is not addressed in a respectful way. It can be especially helpful if you feel hesitant or intimidated to raise a concern to someone you perceive to be in a position of higher authority. You may not need all the steps to obtain the desired results. Here’s how it works:

  • Ask a Question
  • Make a Request
  • Voice a Concern
  • Use Chain of Command

Speak up for Safety

Stop the line when there is an immediate threat

This error prevention tool is used to stop any action and reassess the situation so that everyone is on the same page before continuing. Stopping the line should always be done in a calm and respectful voice. Here’s how it works. Simply say: “please stop the line, I need clarity.” Anyone at MLHS has the authority to STOP THE LINE any time that an immediate threat (real or perceived) to patient or staff safety is identified.

Speak up for Safety

Crucial Conversations

Crucial Conversations is a course that is directly connected to promoting a culture of safety.  It is a tool to use if you need to speak up in a situation that could impact patient safety.  It is being offered to MLH employees in a classroom format.  For more information on Crucial Conversations, contact your manager, or visit the MLH Education & Development Home Page on the Intranet.

Got Your Back!

Peer Checking

This error prevention tool is an easy way to help our coworkers to perform their best. Take advantage of working together to perform fast and easy verifications of each other’s work. Here’s how it works:

  • Offer to check the work of others (second‐check a calculation, proofread a memo)
  • Point out unintended slips and lapses (a supply room key left on the counter, an order placed in the wrong chart)
  • Point out work conditions that your team member might not have noticed (a floor that was mopped and is slippery)

Got Your Back!

Peer Coaching

This error prevention tool is used to address unsafe or unproductive behavior. Peer coaching is different from “checking.”  Coaching requires first observing behaviors and performance of our coworkers then offering coaching where appropriate.  Here’s how it works:

  • Encourage and praise others when they use safe and productive behaviors
  • Discourage and give advice to others when they use unsafe and unproductive behaviors