1. STOP THE LINE!
For patient safety

2. Every Employee is a Patient Safety Inspector

3. STOP THE LINE! Is an alert system that requires all
employees who encounter a situation
likely to harm a patient to make an
immediate report and “Stop the Line!”
(ceasing any activity that could cause
further harm).

4. Every care giver is accountable and supported! Care givers need to:
Watch for threats to the patient’s wellbeing
Take action when a patient is in danger of being harmed
Stop the line before harm happens

5. Summit Healthcare supports a culture of Safety.
It is safe to report mistakes
When mistakes are reported, they will be corrected
Those who report mistakes will be praised

6. When would you use Stop the Line?
Defective equipment
That could cause harm
Register inaccurate results
Medication mistakes
Inexperienced provider doing a procedure incorrectly
Procedures that develop complicated and unanticipated challenges
Inappropriate practitioner behavior

7. It is easy to Stop the Line! when you see
something obvious. For example, if a
patient is being transferred from gurney
to bed and the Foley catheter is caught,
it is easy to tell staff to stop until the
catheter is untangled. It is not as easy to
Stop the Line! in more complex situations
– but it is important for you to be able to
do so!

8. There are three levels of responses to
help you Stop the Line!
Help me understand…..
Time out!
STOP THE LINE!
An appropriate response to any of the
above is:
“I acknowledge your concern”

9. Level One Help me understand…….
This gives the person who is about to cause harm an opportunity to explain rationale to you. The person may see they are making a mistake and self-correct, or they may really help you understand that what they are doing is unusual but will not cause the harm you thought it would.

10. The hospital policy defines level one as:
“State the concern and if the issue is not acknowledged notify the appropriate supervisory personnel.”

11. For example, a physician orders a huge
dose of medication. You know this dose
is significantly higher than is
recommended. You know that patients
who get too much of this medication
usually have bad side effects. What
should you do?

12. Should you tell the doctor he is going to
hurt the patient with that dose and he
needs to change it?
NO!!!
You could say:
“Doctor, help me understand why we are
giving such a large dose of this drug to
this patient”
This gives the doctor the opportunity to
either lower the dose, or explain his
rationale for the larger dose.

13. Level Two
Time out!
If “help me understand…” does not get the response you want, you can call a time out. Everything stops until all parties agree on what is the safe thing to do. The policy states to ask the provider to step away from the patient to discuss the safety concern.

14. Another example: suppose you are a tech
and you are helping your charge nurse
put in a Foley catheter. She obviously
breaks sterile technique as she is
preparing her supplies, but continues on.
You know that the break in technique
could lead to an infection in the patient,
but the charge nurse is intimidating to
you.
What do you do?

15. Should you confront the nurse?
“You broke sterile technique and now the patient might get an infection”
NO!!

16. You attempt to use a level one
statement:
“Help me understand why you are not
getting another sterile kit to complete this
procedure”
The nurse responds:
“Because I am the nurse and you are the
tech, that’s why!”

17. Since Level One did not work, you can move to Level Two:
“Time out! Let me go get another sterile
kit for you.”

18. Level Three STOP THE LINE!
When the first two levels are not successful at stopping the dangerous behavior, STOP THE LINE! requires activation of the chain of command.

19. The hospital policy defines this level as a
definitive, non-appealable cessation of
activity. In the event the activity causing
concern cannot be stopped, the person
causing the concern acknowledges the
problem and all possible steps to prevent
harm are taken.

20. For example, you are assisting the physician
with a thoracentesis. Although the order,
consent, and x-ray all show the problem is
on the patient’s left side, the physician
begins to prepare the right side for the
procedure. Levels one and two did not work,
and you are worried the physician will go
ahead with a procedure on the wrong
Site. STOP THE LINE! requires
everything to stop until the issue is
resolved.

21. Sometimes, the person who is doing the
act you think may be unsafe cannot stop.
At that time, the person may say that
they acknowledge your concern. This
means the person is aware of the safety
issue and because he/ she cannot stop,
he/ she will proceed with safety in mind.

22. Remember!
When you use STOP THE LINE! be
sure to involve your supervisor and the
chain of command!

23. More examples of benefits of using STOP THE LINE!
A patient was harmed by an
illegible pharmacy order that
was misinterpreted by both a
pharmacist and a nurse. STOP
THE LINE! would have helped
clarify the order before the
danger reached the patient!

24. More examples…… You suspect a healthcare provider is
impaired from drugs or alcohol. Do
you let the provider continue to give
care or do you STOP THE LINE?

25. So… is STOP THE LINE! only for clinical staff?

26. No! STOP THE LINE! is for all hospital
employees! Situations where non-clinical
staff may use this might include the following:
A housekeeper observes a plant services employee climb on a broken ladder.
Someone from medical records observes a housekeeper plugging in a vacuum with a frayed power cord.
An admissions clerk observes a tech putting a patient into a broken wheelchair.
A nurse asks three men from plant services to help her lift a heavy patient.

27. Documentation Whenever any level of STOP THE LINE! is
used, the event should be documented in
Quantros. All STOP THE LINE! events will be
reviewed to be sure of three things:
Was safety an issue?
Were the individuals acting in good faith?
Was chain of command followed?

28. Barriers to using STOP THE LINE:
Reluctance to report:
Employees often fail to report problems and errors because of fears of retribution from peers and supervisors. People can be intimidated to not address errors made by people higher then them in their chain of command.
Culture of blame: The presumption that error occurred because of incompetence.
Culture of Secrecy: Knowledge of medical errors are limited to as few people as possible. This can result in safety lessons not being broadly applied.

29. Hard but Necessary STOP THE LINE! is serious business
Not about hierarchy
Not about politics
Not about friendship or popularity
This is about protecting patients and
doing whatever is necessary to provide
the highest quality of care!