Pointing and calling the way to patient safety: An introduction and initial use case

Abstract

Background

Using tools from outside healthcare can help improve patient safety. Pointing and Calling (Shisa Kanko) is an operational procedure developed for industry in Japan to prevent human error and has been used in healthcare in Asian countries to reduce errors during medication administration. Pointing and Calling affects cognitive task switching by pointing to a place or object and calling out the operation to be performed.

Aim

Conduct an initial use case to examine the willingness and ability of healthcare professionals in a Western country to use Pointing and Calling.

Methods

An observational initial use case was conducted with nineteen Advanced Care Paramedic students. Confidence, perceptions, and use of Pointing and Calling were measured during a simulated clinical scenario along with facilitator perceptions.

Results

After the simulation participants were confident in their ability to use Pointing and Calling, found the method to be beneficial, and indicated they would use Pointing and Calling in the future. Participants often used the method for tasks such as checking vitals. Aspects of the method requiring clarification and more training were identified. Facilitators indicated the method appeared beneficial during simulations and could be incorporated into existing curriculum.

Conclusions

The benefits of Pointing and Calling are readily apparent to students and facilitators and both groups are receptive to the method. Pointing and Calling is low risk with substantial potential benefits. With more education and training Pointing and Calling could be effectively implemented.

Keywords

safety paramedics performance improvement errors risk management shisa kanko‌

Introduction

Medical error and patient harm continue to be a problem in healthcare,¹ looking to areas outside of healthcare, such as aviation, industry, and the military, can provide new approaches to improve patient safety.^2,3 The current paper presents a method largely unknown in Western countries with high potential to improve patient safety and reports the results of an initial use case.

The “new” method: pointing and calling (Shisa Kanko)

James Reason is a luminary from outside of medicine with a major influence on safety in medicine; however, if Reason had been familiar with a Japanese method for improving safety a serendipitous event that led him to safety science may never have occurred:

“One afternoon in the early 1970s, I was boiling a kettle of tea. The teapot (those were the days when tea leaves went into the pot rather than teabags) was waiting open-topped on the kitchen surface. At that moment, the cat – a very noisy Burmese – turned up at the nearby kitchen door, howling to be fed. I have to confess I was slightly nervous of this cat and his needs tended to get priority. I opened a tin of cat food, dug in a spoon and dolloped a large spoonful of cat food into the teapot. I did not put tea leaves in the cat’s bowl. It was an asymmetrical behavioural spoonerism”.⁴

The similarity and concomitance of the two events led to the error;⁵ using Pointing and Calling (P&C), or as termed in Japan ‘Shisa Kanko’, would have helped Reason avoid the error. While we would have been deprived of Reason's influence, the implementation of P&C can prevent serious errors from occurring.

What is pointing & calling?

Most simply, P&C is an operational procedure involving pointing to a place or object and calling out the operation to be performed developed for industry in Japan to prevent human error.^6,7 For example, before turning across traffic a bus driver would point to their left and call out if it is clear, then repeat the same action to the right, before proceeding to turn. P&C was introduced in Japan as a part of the Japan International Center for Occupational Safety and Health (JICOSH)¹ “Concept of ‘Zero-accident Total Participation Campaign”.⁷ Research on P&C in Japan has shown reduced human error in decision making⁶ and improved operating procedures.^8–10

P&C is a Non-Technical Skill (NTS), a cognitive, social or personal skill that improves safety by supporting technical skills. NTS's are becoming recognized as necessary and essential in healthcare.¹¹ Pointing and Calling reduces cognitive errors by improving environmental engagement.⁸ The mechanism underlying the effectiveness of P&C is engagement of executive functioning to change situational awareness and signal action response through cognitive task switching.^6,12 Cognitive task switching is the active retrieval of a task set or rule different from the previous task set being employed.⁶ The neurological effect of P&C is evidenced by increased brain activity in the prefrontal and visual cortex.¹²

Implementation of pointing & calling

Due to the demonstrated effectiveness of P&C in reducing workplace errors, P&C has become a standard workplace safety method and aspect of corporate culture throughout Japan and other countries in Asia.^7,13 P&C is most prominently applied in the Japanese rail industry where P&C is used by conductors and station staff to ensure conditions are safe and proper operating procedures are being followed.^14,15 The use of P&C in the Japanese rail system has shown work related errors are reduced by 85% compared with not using P&C.⁷ P&C has also been successfully implemented in rail systems outside of Japan such as New Zealand,⁸ Taiwan, Hong Kong and China¹³ and the New York City subway system.¹⁶ O’Connell et al.⁸ found P&C was effective for increasing the accuracy of driver signal response and in reducing the risk of danger signals passed by conductors for KiwiRail, New Zealand's national railway network. Pointing and Calling can improve road safety by improving attention and reducing traffic accidents in elderly drivers,⁹ firefighters, the general population¹⁰ and has improved bus safety in the Taipei transit system.¹⁷ Interest has been spurred in aviation to use P&C to improve safety by supplementing procedures such as flight deck crosschecking, course changes, taxiing, and maintenance.¹⁸

P&C has also been applied in healthcare in Asian countries. In an experimental study in Japan, nurses who use pointing, though not calling, were better able to select the proper drug among similarly named drugs for administration in comparison to a control group that did not use pointing.¹⁹ In another Japanese study when fake pseudo drug names were used finger pointing with no calling was found to be less effective than pointing and calling, with practicing nurses making significantly more errors than students in drug selection. The discrepancy between students and nurses may have been due to nurse familiarity with drug names and the use of top-down processing in identifying the drug to be used,¹⁹ however the results indicate P&C is effective in improving drug selection. In a hospital in Hong Kong, 1100 nurses participated in an intensive training programme on the use of P&C. Training included briefing sessions, seminars, and repeated demonstration and practice sessions. Nurses reported positive perceptions of the benefits of P&C and positive self-perceptions of being able to use P&C. After receiving P&C training nurses adhered to using P&C 98–100% of the time. Most importantly, P&C was effective for reducing errors in the use of “high alert” medications administered through infusion or syringes. In the same study, after support for P&C by administration was discontinued P&C compliance dropped and the rate of medication errors increased.²⁰

Pointing & calling for reducing errors in healthcare

The use of P&C could be applied to any discipline in healthcare with numerous applications including, but not limited to, supplementing checklists, supporting teamwork, and ensuring procedural accuracy. In a post-surgical context when using an instrument checklist, pointing to and calling out the name of instruments used would help assure that all instruments are accounted for and foreseeably reduce the rate of Retained Foreign Objects. The use of P&C is a secondary assurance that all steps of the checklist have been followed properly and any interrupted steps are repeated, retaining procedural continuity. Many healthcare providers have clear guidelines and procedures for technical skills. For nurses administering medication there are checklists that outline medication specifics such as Right Client, Medication, Dose, Route, Time and Frequency that must be followed before medication is administered.²¹ Implementing P&C at the beginning of each check can ensure the nurse is intently and consciously reviewing the checks prior to administration.

A recent case of error involving medication administration resulting in patient death and litigation against the nurse responsible and the medical centre exemplifies how P&C could prevent such errors. The medication intended to be administered was an anti-anxiety drug midazolam under the brand name Versed, however the drug administered was vecuronium, a paralytic. The medication names which begin with the same first two letters could have been mistaken due to fatigue or time pressures. To access the drug, the nurse used a medication override function intended to bypass the need for verification from a pharmacist, in case of an emergency.²² Pointing and Calling could have been used as an additional check after the medication override function was engaged. Using P&C would not have delayed administration and likely would have helped ensure the correct drug was selected.

Challenges

The greatest challenge to implementing P&C is the perception of P&C as being awkward or comical, and self-consciousness about using P&C if observers find the method to appear strange.^14,17 If P&C is seen as abstruse and humorous it may be met with resistance. Education can lower the barriers to implementing, testing, and maintaining P&C through education on the successful uses of P&C for improving safety, continuous education on using the method, and support and modelling from leading practitioners who promote culture change.²³ P&C should be emphasized as a simple way to improve task awareness and performance rather than being an addition to workload.²⁰ Incorporating P&C early in health professional's education and assessment as an essential standardized procedure could support rapid adoption. Learning P&C in interprofessional settings could also improve familiarity and acceptance across professions, reducing self-consciousness. For pedagogical purposes, relating P&C to currently accepted NTS's such as closed loop feedback, by framing P&C as individual closed loop feedback, may make acceptance easier.

In conditions with numerous operations, signals, and time pressures, performing P&C can be challenging, leading to high cognitive load and P&C being neglected,⁶ practice in stressful simulated scenarios with feedback and assessment can mitigate these challenges.²³

Concern may arise about negative connotations regarding the term Finger Pointing as it can relate to laying blame. Pointing and Calling is a term that indicates a very specific behaviour independent of any negative connotations, such as placing blame. Pointing and Calling is a behaviour that fits with current models of promoting patient safety and moving away from blame to a safety culture. Adopting a different name would obfuscate the concise and direct descriptive quality of the term P&C and create confusion when communicating with disciplines outside of healthcare.

How to point and call

Pointing and Calling is an effective yet simple method to use. Implementation requires support and modelling from management (Table 1).

Table 1.

Instructions and Implementation of Pointing and Calling.⁷

Instructions on Pointing and Calling “This activity involves pointing at target objects by stretching your arm and stating out loud, ‘Such and such is OK’ at important points in the work in order to proceed with work safely and correctly. Pointing and calling are methods for raising the consciousness level of workers and confirming that conditions are regular and clear, increasing the accuracy and safety of work. This method for ensuring safety is based on the philosophy of respecting human life and can be achieved only with the full participation of the workforce in practice activities across the whole of the workplace.”

How to Implement P&C in the Workplace²⁴ 1. Detailed planning, promotion and training: map out a detailed and comprehensive training plan to implement P&C, then the managers and frontline workers should meet and discuss dangerous spots in the workplace and identify how to apply FPC. Managers should make efforts to minimize the embarrassment of the practice. 2. Supervisors take the lead and workers follow: the managers should act as a model to use P&C in the workplace and facilitate practice regularly to increase the use of P&C, so that the workers will pick up this skill as a habit gradually. 3. Simple and precise slogans with clear steps: design an easy slogan suitable for confirmation in the particular workplace.

Initial use case

An initial use case was conducted with Advanced Care Paramedic (ACP) students in a simulated scenario to examine the viability of introducing P&C in Western healthcare systems. Before embarking on large scale investigations or implementation it is necessary to conduct an initial use case, or alpha testing, to garner design input and determine initial perceptions, understanding, use, early risk analysis, and receptiveness.²⁵ Paramedics were selected for the study as Emergency Medical Services (EMS) function in diverse and dynamic environments, and must possess and use a range of skills, knowledge, and tools. The dynamic and evolving scenarios EMS function in provide an ideal initial use case for P&C. Two research questions were developed:

Research questions

Will healthcare students in North America be willing and able to implement Pointing and Calling during simulation?

What are healthcare students’ perceptions about using Pointing and Calling?

Methods

Participants

First-year ACP students at the Northern Alberta Institute of Technology were recruited to participate. All students in the first-year cohort were eligible to participate. Participants were recruited to the study during class time. The Principal Investigator (PI), who was not previously known to students, introduced the study to participants. Interested participants were emailed a link to the consent form and study information hosted on Qualtrics.²⁶ All participants completed a consent form prior to participation in the study. Ethics approval was granted by the Northern Alberta Institute of Technology Research Ethics Board (#2021-04).

Procedures

The study was run during simulations conducted as part of the regularly scheduled curriculum during the 2021 winter semester. Participants were grouped in existing cohorts of 5–6 students and moved through three simulations; two simulations were designated for participants to use P&C. The designated simulations involved intentional overdoses with the opportunity for IV use, drug administration, and intubation. Simulations involved four participants while the other students observed. All students participated in at least one of the simulations where P&C was to be used.

Instruction on pointing and calling

Prior to the simulations all participants were provided training on P&C that emphasized P&C as a simple way to improve task awareness and performance. The training included a didactic portion where the background and purpose of P&C and how P&C works were presented along with situations during practice when P&C could be used. Emphasis was placed on P&C as a NTS in the form of individual closed loop feedback. Participants were then shown a short video that presented the history and effectiveness of P&C and demonstrated how P&C is used.²⁷ After the video, situations involving medication administration, administering an IV, and intubation were emphasized as ideal opportunities to use P&C. Participants were also told to use the method in any situation they found appropriate. Next, as a group, participants practiced the method multiple times by 1) P&C to identify a specific drug from a list of drugs presented on a screen, 2) finding and pointing to the same drug in their reference guide and 3) calling out the drug name and recommended dosing protocol. To provide support and modelling, programme instructors stood at the front of the classroom and practiced the method with students. Participants then completed a brief survey to gauge their comprehension of P&C.

Prior to the designated simulations participants were reminded and encouraged to use P&C. All simulations were audio and video recorded. After the simulation and prior to debriefing participants completed a survey about the use of P&C. After the simulations, the two simulation facilitators, who are also programme instructors, completed a set of questions about P&C.

Analysis

Survey results were analysed for response frequencies. Constructed-response items were read and coded. Videos were watched by the PI to understand participants use of P&C. As the simulation was an unstructured exploratory investigation of P&C frequencies of behaviour were not directly recorded, rather general attempts at using P&C and the situations where students used P&C were examined to understand use behaviour. Facilitator responses to questions were reviewed.

Results

All 19 students in the first year ACP cohort completed the consent form and participated in the simulations. The pre-simulation survey was completed by 17/19 participants, 14/19 completed the post-simulation survey. Video was obtained for all six of the simulation sessions. Both facilitators completed questions about P&C.

Survey data

Pre-simulation survey

For the majority of participants (15) the purpose of P&C was clear, for two the purpose was somewhat clear. Eleven participants were clear on what they were being asked to do during the simulations, five were somewhat clear and one was unclear. Eleven participants were somewhat confident in being able to perform P&C during the simulation, four were highly confident, and two were not at all confident. All but one student indicated they would attempt to use P&C during the simulation. Overall, participants understood the purpose of the study and what was being asked of them.

Post-simulation survey

The purpose of P&C remained clear to the majority of participants (11) with two somewhat clear and one unclear. During the simulation eight participants felt somewhat confident using P&C, four felt highly confident and two were not at all confident (see Table 2).

Table 2.

Post-Simulation survey results.

	Response*
Survey Item	Yes	No
Did you find Pointing and Calling easy to use?	9	5
Did you find Pointing and Calling awkward?	11	3
Do you think Pointing and Calling helped you complete the simulation more accurately?	7	7
Would you try and use Pointing and Calling in the future?	10	4
Do you think Pointing and Calling could benefit you while working?	11	3

*n = 14.

Post-simulation constructed-response

Pointing and calling is effective and helpful but requires adaptation

After getting past the strangeness and awkwardness of P&C participants found using P&C to be helpful and efficient ensuring attention was focused on the task being performed “It was a little strange at first, but I definitely see the benefit”. Participants thought other healthcare workers might see P&C as strange, however understanding the method and seeing the benefit would help people accept it. Participants thought once P&C became “mainstream” it would no longer be seen as strange. The instruction prior to simulation was clear. Participants expected more training would make P&C easier to use and training would be necessary to change how people normally work “I have my normal way of doing things and muscle memory took over”. Some participants did not notice any benefits or detriments to using P&C and were unsure how P&C would have changed the outcomes of the simulations.

Challenges of pointing and calling

Participants identified two potential challenges to implementing the method. 1) Negative reception by colleagues. Participants thought some people might view P&C as a method for delegating and would not like it. 2) Pointing and Calling could be intrusive. Participants thought some people may find P&C to be another technique being added to many others and would see P&C as a burden. Participants also thought that while P&C was useful, at times P&C could become difficult or impossible to use when “you have both hands occupied” or a situation became busy.

Observational

Pointing and Calling was used most frequently in three situations. Participants in every cohort used P&C multiple times when: 1) Checking and reporting Blood Pressure and blood oxygen saturations (participants would point to the monitor and call out the BP and SP0²); 2) When obtaining and exchanging equipment (e.g. obtaining and giving an oxygen bottle to a team member); 3) Reminding themselves what tasks have been carried out or indicating to team members arriving on the scene what tasks had been carried out.

In three situations P&C was used less frequently by fewer participants: 1) Selecting medication from the kit and drawing and administering the medication; 2) Inserting a line for an IV and confirming the IV was going and what was being giving; 3) The team lead identifying team members and delegating tasks.

Four unique situations arose where P&C was used: 1) Identifying and bandaging the patients self-inflicted wounds; 2) Administering oxygen, specifically when opening the bottle and then checking the patient was receiving 0² “wide open (pause) receiving oxygen”; 3) Moving the patient's bed; 4) Checking end tidal after intubation. In cases three and four only single instances of the action, bed moving and intubation, occurred across all simulations.

Typically, when first attempting to use P&C participants laughed and demonstrated some awkwardness. Some participants used P&C with high frequency, some tried once or twice then stopped, and some did not use P&C at all. Pointing and Calling was used less frequently towards the end of simulations.

Facilitator responses

After observation both facilitators saw the benefit of P&C, particularly in forcing people to double check what they thought was correct. Facilitators saw the most consistent use of P&C when incorporated with communication and thought P&C should be used in conjunction with, but not to the exclusion of, other communication techniques and integrating P&C into EMS practice would be effective and essential, particularly in busy situations with multiple treatments being performed. Facilitators expected practicing EMS would be resistant to the method and adoption and implementation would require demonstrations of effectiveness, evidence of efficacy, and reinforcement by employers. For adoption by students’ facilitators thought introducing P&C early in a programme, showing students how to use P&C effectively, and maintaining emphasis throughout the programme would be necessary until P&C became second nature.

To effectively incorporate P&C in education, facilitators thought the method should be introduced with other communication techniques and CRM, such as during TeamSTEPPS.²⁸ Facilitators believed gathering more evidence for P&C would be helpful and necessary to create course content but foresaw no practical barriers to implementing P&C. Finally, facilitators identified that improving accuracy and safety is a major issue for EMS and P&C could help “I think the sooner this is integrated into the profession the less adverse events we will see”.

Discussion

Both research questions were answered in the affirmative; healthcare students were willing and able to use P&C, were somewhat confident using P&C, and found the method to be beneficial, albeit awkward. Participants often used P&C for certain tasks, such as checking vitals, and could use P&C more frequently for tasks such as administering medication. Participants indicated they would use P&C in the future though more training would be helpful. Facilitators indicated the method appeared beneficial and could be incorporated into curriculum though implementing P&C with practicing EMS was expected to be more challenging. Practical and interpersonal challenges were identified as well as aspects of P&C requiring clarification.

Implementation and future directions

The benefits of P&C were apparent to students and instructors and both groups were receptive to the method. To ensure effective use, future implementation of P&C would require more education, training and practice than delivered in this study. Greater clarification of P&C appears necessary, some participants thought of, and used, P&C as a method for delegation. It is particularly important to clarify to users that Pointing and Calling is not Pointing and Telling. Pointing and Calling is a NTS with a specific definition and purpose, cognitive task switching, and is not intended for delegation. Pointing and Telling can be effective in certain situations, such as when help is needed and there are inactive by-standers²⁹ and is taught in First Aid courses.³⁰ Emphasizing the distinctions must be made explicit to remove any negative connotations, associations, or perceptions about P&C. Education and training should stress that P&C is an essential aspect of communication and safety and is not another intrusive technique amongst a repertoire of other methods. Emphasizing P&C as a form of closed loop communication appeared to be effective.

Finally, it is necessary to determine and train specific cases or tasks where P&C would be used by different professions. For any profession three types of tasks can be identified. 1) Linear, frequent, routine, automatic or repetitive procedural tasks with well-defined outcomes such as medication administration and using checklists. These would be ideal for initial implementation and teaching. 2) Tasks based on important professional competencies. 3) Critical tasks with a high risk of failure or where a mistake could be catastrophic.

Existing evidence indicates P&C is an effective method for reducing procedural errors that Western healthcare professionals are willing to use. There are two concurrent future directions for P&C in Western countries.

1) Experimentally test P&C in educational and simulated environments to identify tasks or procedures where P&C will be most effective and to understand the best methods of teaching P&C and improving acceptance.

2) Promote education and use P&C in practice. Two threads of reasoning support implementing the use of P&C. A) Evidence for P&C should not be disregarded or considered invalid simply because it is not from North America or Europe/UK. Ample evidence from Asian countries exists for the efficacy of P&C for multiple professions, including in healthcare, along with how to use P&C. B) Reasonable risk, there is no apparent risk to implementing P&C as research on the method continues. Risk is defined as “the probability that a substance or situation will produce harm under specified condition” or the “effect of uncertainty on objectives” and is a combination of two factors; the probability that an adverse event will occur and the consequences or severity of the adverse event.^31,32 Pointing and Calling meets the risk management criteria of ‘As Low As Reasonably Practical’ (ALARP) risk. When considering the risk for P&C; Risk Probability would be “Extremely Improbable” and Risk Severity would be “Negligible” producing a “Very Low” Risk Assessment rating.³¹ Conversely the potential for improving safety and reducing patient harm is substantial. Additionally, some people already naturally use a personal variation of P&C, one participant commented “I do it naturally in my work environment. Nothing new.” Standardizing, formalizing, and disseminating P&C across systems would ensure a good practice used by a few becomes commonplace.

Limitations

The present study was single site, small-scale, with students in a single profession, and limited instruction was provided. Further, the study did not assess the clinical efficacy of P&C for reducing the incidence of adverse events due to the misidentification of patients, medication, procedural errors, or other causes. As P&C is generally unknown in the West it was necessary to first introduce P&C and conduct an initial use case. Future research should expand the scope and rigour of testing P&C to include assessment of the clinical efficacy of the intervention. An additional limitation is a possible social desirability effect on participants. Participants may have perceived the researcher to be enthusiastic about the intervention and based on the use of class time for the study and modelling, instructors as supportive of the intervention. These conditions may have led to more positive perceptions and acceptance of P&C by participants. While support and modelling from leadership is necessary for the successful implementation of P&C²³ future research should attempt to control for social desirability effects.

Conclusion

Following Reason's legacy P&C brings together different lines of thought into a coherent framework to understand and address the complex cognitive process that underly the diversity of errors.⁵ By introducing and testing P&C this study follows the systemic approach of safety science, which is based on exploring new paradigms and tools from outside areas and combining multiple forms of study including empirical and ethnographic studies, and theoretical and practical work.^5,33 Pointing and Calling has been primarily used in Asian countries and information and research can be challenging to access due to language barriers. The result has been that a method for reducing patient harm and improving safety is largely unknown in Western countries. Pointing and Calling should not be a piece of esoterica but a well understood, thoroughly investigated, and widely implemented, method for reducing patient harm. The promise of P&C presents an opportunity for international cooperation and overcoming language and cultural barriers to improve patient safety. Pointing and Calling can help ensure the proper drug is administered, the checklist is followed, the train platform is clear, and the cat is fed.

Footnotes

Acknowledgments

The authors would like to acknowledge the support of the Advanced Care Paramedic Program at Northern Alberta Institute of Technology

Authors contributions

Efrem Violato – study conception, design, data collection, data analysis, interpretation of the data, drafting of manuscript, final approval of the manuscript

Iris Cheng In Chao - study conception, design, interpretation of the data, drafting of manuscript, final approval of the manuscript

Charlotte McCartan - study conception, design, interpretation of the data, drafting of manuscript, final approval of the manuscript

Brendan Concannon - study conception, design, interpretation of the data, drafting of manuscript, final approval of the manuscript

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a Mitacs Accelerate Grant (grant number ITI8354).

Data Availability

Data can be made available upon reasonable request

Competing Interests:

Efrem Violato has no competing interests to declare

Iris Cheng In Chao has no competing interests to declare

Charlotte McCartan has no competing interests to declare

Brendan Concannon has no competing interests to declare

Reporting: This study followed The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies.

Ethics Approval: The study, including all procedures and processes, materials, and plans for analysis and dissemination was reviewed by the independent ethics review board at the Northern Alberta Institute of technology. Ethics approval was granted by the Northern Alberta Institute of Technology Research Ethics Board (#2021-04).

Consent to Participate: All participants completed a consent form prior to participation in the study. All participants gave free and informed consent to participate and have their data included in the study

Guarantor: Efrem Violato accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish

ORCID iD

Efrem Violato

Notes

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