The Science Journal of the American Association for Respiratory Care

2009 OPEN FORUM Abstracts

USING TOYOTA PRODUCTION SYSTEM METHODOLOGY TO IMPROVE SAFETY OF TRACHEOSTOMY TUBE SPEAKING VALVES

Robert Hase1, Jeff Suenaga1, James M. Marshall2; 1Respiratory Care, Virginia Mason Medical Center, Seattle, WA; 2Speech-Language Pathology, Virginnia Mason Medical Center, Seattle, WA

Background: One-way speaking valves used with cuffed tracheostomy tubes carry an intrinsic dangerous potential if the cuff is inflated when the speaking valve is attached. This is compounded when bedside caregivers are marginally familiar with these devices. Traditional approaches to maximize safety include placing a warning flag on the pilot balloon, as well as universal education. Our facility employed these and other methods but lacked confidence regarding patient safety. Methods: We convened a work team to design a process change ensuring patient safety even when caregivers had minimal exposure to speaking valves and/or tracheostomy tubes. Our goal was to error-proof the system whereby standard procedures would be followed to maintain the tracheostomy cuff (call RT) and the cuff would not be inflated by well-meaning but untrained clinical staff. We performed root-cause analysis of potential errors, and then devised a prototype device using Toyota Production System (TPS) theory, that we tested over a course of PDSA (plan-do-studyact) cycles. Results: We were able to construct a device that prevents cuff inflation in conjunction with a speaking valve. Our device employs TPS elements of warning and control poke-yoke, as well as visual control. Conclusions. We improved safety at our facility for patients with speaking valves attached to cuffed tracheostomy tubes, using Toyota Production System methodoloy. Sponsored Research - None

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