Download - Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008
Culture of SafetyCulture of Safety
HSC Faculty Development HSC Faculty Development ProgramProgram
Niti Armistead, MD FACPNiti Armistead, MD FACP
October 30October 30thth, 2008, 2008
ObjectivesObjectives
Safety from a patient’s perspectiveSafety from a patient’s perspective Case scenarios from closer to homeCase scenarios from closer to home Science of safetyScience of safety Importance of teamwork and Importance of teamwork and
communicationcommunication Theory to practice: required Theory to practice: required
elementselements
Josie King Josie King
Spot for videoSpot for video
Audience Thoughts…Audience Thoughts…
How could this story happen?How could this story happen?
Could this happen at any Healthcare Could this happen at any Healthcare facility, including WVUH?facility, including WVUH?
Does organizational “culture” have Does organizational “culture” have any role in this issue?any role in this issue?
Case Scenario #1Case Scenario #1
Mr. Jones is a 89 year old man involved Mr. Jones is a 89 year old man involved in a motor vehicle accident 1 month in a motor vehicle accident 1 month prior to admission. Over the month, prior to admission. Over the month, he became progressively confused and he became progressively confused and lethargic. Head CT by PCP revealed a lethargic. Head CT by PCP revealed a large left sided subdural hematoma. large left sided subdural hematoma. He was transferred to our facility for He was transferred to our facility for further evaluation and treatment.further evaluation and treatment.
Case Scenario #1Case Scenario #1 Upon admission to SICU, patient’s wife Upon admission to SICU, patient’s wife
was consented for a left twist drill was consented for a left twist drill procedure for insertion of a drainage procedure for insertion of a drainage catheter. Dr Smith marked the site while catheter. Dr Smith marked the site while the family was present in the room, while the family was present in the room, while he was talking with them. Family left the he was talking with them. Family left the room just prior to the procedure. RNs room just prior to the procedure. RNs John and Susan were in and out of the John and Susan were in and out of the room at various times. John was the stat room at various times. John was the stat nurse and Susan had another patient nurse and Susan had another patient assignment. It was shift change and there assignment. It was shift change and there was a lot of activity in the unit, including was a lot of activity in the unit, including many visitors and calls.many visitors and calls.
Procedure Procedure Dr Smith shaved a small spot on the Dr Smith shaved a small spot on the
scalp and prepped the area with scalp and prepped the area with chloraprep. He placed a drain on the chloraprep. He placed a drain on the right side of the head. There was no right side of the head. There was no drainage noted. Immediately Dr Smith drainage noted. Immediately Dr Smith realized he had placed the drain on the realized he had placed the drain on the wrong side. He successfully went on to wrong side. He successfully went on to place another drain on the left side. place another drain on the left side.
There is a space on the sedation form There is a space on the sedation form for the surgical pause and site for the surgical pause and site validation. This space was left blank.validation. This space was left blank.Mr. Jones suffered no direct harm from Mr. Jones suffered no direct harm from the placement of either drain. the placement of either drain.
Case Scenario #1Case Scenario #1
How could this wrong-site procedure How could this wrong-site procedure have been prevented?have been prevented?
Science of SafetyScience of Safety
Late 1999, Institute of Medicine (IOM) Late 1999, Institute of Medicine (IOM) published a report, “To Err is Human: published a report, “To Err is Human: Building a Safer Health System” Building a Safer Health System”
Estimated 44,000 to 98,000 deaths from Estimated 44,000 to 98,000 deaths from errorserrors
““Equivalent of a jumbo jet crashing Equivalent of a jumbo jet crashing each and every day in the U.S.”each and every day in the U.S.”
Generally not an issue of “bad apples”Generally not an issue of “bad apples” Challenge: build a system that catches Challenge: build a system that catches
the inevitable lapses of mortalsthe inevitable lapses of mortals11
1. Wachter, Shojania. Internal Bleeding. New York, NY: Rugged Land, 2004
The Swiss Cheese Model of The Swiss Cheese Model of SafetySafety
Some holes dueto active failures
Other holes due tosystem design
Hazards
Error Reaches Patient
Layers of Protection
James Reason, Human error
Science of SafetyScience of Safety
All healthcare encounters
All errors
“near miss”
All adverse eventsPreventabl
e adverse events
Non-preventable adverse eventsNeglige
nt adverse events
Wachter. Understanding Patient Safety, McGraw Hill, NY 2008
Quality versus Safety: for Quality versus Safety: for example…example…
Patient comes in to ED with chest pain. Patient comes in to ED with chest pain. His EKG shows ST elevation, suggesting His EKG shows ST elevation, suggesting acute MI. He receives an aspirin and a acute MI. He receives an aspirin and a beta-blocker and taken to the cath lab beta-blocker and taken to the cath lab immediately. In the post procedure time, immediately. In the post procedure time, he receives his metformin and 2 doses of he receives his metformin and 2 doses of ibuprofen. Patient’s hospital stay is ibuprofen. Patient’s hospital stay is complicated by acute renal failure.complicated by acute renal failure. Acute MI quality process measures met? Yes. Acute MI quality process measures met? Yes.
This is publicly reported and relatively easily This is publicly reported and relatively easily measured. measured.
Was his “safety” optimized? No. This is not as Was his “safety” optimized? No. This is not as easily detected!easily detected!
Science of SafetyScience of Safety
What does system-focused approach look What does system-focused approach look like?like? TechnologyTechnology PracticesPractices ProceduresProcedures PoliciesPolicies Culture!Culture!
Culture: collection of values, beliefs and Culture: collection of values, beliefs and assumptions that guide members’ assumptions that guide members’ behaviorsbehaviorsPronovost et al, Implementing and Validating a Comprehensive Unit-Based Safety program, Journal of Patient Safety. March 2005
Culture of SafetyCulture of Safety
Culture: “the way we do things Culture: “the way we do things around here”around here”
Culture Eats Strategy for Lunch
What is a Safe Culture?What is a Safe Culture?
““In a safe culture, employees are guided by In a safe culture, employees are guided by an organization wide commitment to safety, in an organization wide commitment to safety, in which each member upholds their own safety which each member upholds their own safety norms and those of their coworkers”norms and those of their coworkers”
Aviation industry experience supports an Aviation industry experience supports an association between culture and error association between culture and error managementmanagement
Teamwork: training diverse crews to dampen Teamwork: training diverse crews to dampen steep and unyielding authority gradientssteep and unyielding authority gradients
Communication: clear, timely, closed, Communication: clear, timely, closed, structuredstructured
Lessons from Other Lessons from Other IndustriesIndustries
Preflight briefings and Preflight briefings and checklistschecklists
Call-outsCall-outs Standard proceduresStandard procedures TerminologyTerminology Mitigate error Mitigate error
consequencesconsequences TeamworkTeamwork LeadershipLeadership
Every defect is Every defect is learned in real timelearned in real time
Production is Production is stopped, Any one can stopped, Any one can stop the line! (gidoka)stop the line! (gidoka)
Defect is resolved Defect is resolved and they learn from and they learn from the defect (Kaizen)the defect (Kaizen)
Eliminate waste Eliminate waste (muda)(muda)
CUSP 6 stepsCUSP 6 steps1.1. Evaluate-AHRQ Survey ToolEvaluate-AHRQ Survey Tool
2.2. Educate on science of safety Educate on science of safety
3.3. Identify defects as a unitIdentify defects as a unit
4.4. Adopt interventionsAdopt interventions
5.5. Learn from defect and othersLearn from defect and others
6.6. EvaluateEvaluate
Johns Hopkins Experience: Johns Hopkins Experience: Comprehensive Unit-Based Safety Comprehensive Unit-Based Safety
ProgramProgram
Johns Hopkins Experience: Johns Hopkins Experience: Comprehensive Unit-Based Safety Comprehensive Unit-Based Safety
ProgramProgram Results:Results:
Significant improvement in staffs’ Significant improvement in staffs’ perception about patient safety and perception about patient safety and safety climate.safety climate.
Several safety initiatives implemented Several safety initiatives implemented e.g. ICU daily goals sheet and e.g. ICU daily goals sheet and medication reconciliationmedication reconciliation
Reduction in ICU nursing turnoverReduction in ICU nursing turnover Reduction in ICU length of stayReduction in ICU length of stay
Teamwork and Teamwork and CommunicationCommunication
0
10
20
30
40
50
60
70
80
teamwork in OR
Attending Surgeon
Anesthesiologist
Surgical RN
CRNA Anesthesia Resident
Sexton et al. Errors, stress and teamwork in medicine and aviation, BMJ 2000; 320: 745-749
Teamwork and Teamwork and CommunicationCommunication
All organizations need structure and All organizations need structure and hierarchieshierarchies
Taken to extreme, rigid hierarchies lead to Taken to extreme, rigid hierarchies lead to frontline staff not “speaking up”frontline staff not “speaking up”
Healthcare is different from aviation:Healthcare is different from aviation: ““team” is very heterogeneous: training, income, team” is very heterogeneous: training, income,
statusstatus Come to expect a norm of faulty and incomplete Come to expect a norm of faulty and incomplete
exchange of informationexchange of information When in doubt, we default to “it must be OK”When in doubt, we default to “it must be OK”
Need to change mindset to: “if you’re not sure Need to change mindset to: “if you’re not sure it’s right, assume it is wrong”it’s right, assume it is wrong”
To Err is Human, To Fail is Swiss To Err is Human, To Fail is Swiss
Cheese?Cheese? Site marking done while MD distracted
Environmental factors
No X-ray confirmation
No time out conductedWrong site procedure
No one said: “stop! Let’s take a time out!”
Infant was ordered calcium gluconate for low calcium. MD Infant was ordered calcium gluconate for low calcium. MD entered order for calcium gluconate 400 mg entered order for calcium gluconate 400 mg (100mg/kg) IV push. The peds pharmacist (working on (100mg/kg) IV push. The peds pharmacist (working on 6th floor) checked the initial order and sent labels to 6th floor) checked the initial order and sent labels to the IV room (4th floor). the IV room (4th floor).
The IV room tech drew up 40 ml (4000 mg), the dose was The IV room tech drew up 40 ml (4000 mg), the dose was checked and sent to the floor.checked and sent to the floor.
The nurse administering the doses was uncomfortable with The nurse administering the doses was uncomfortable with the syringe size (60ml) and called the peds pharmacy to the syringe size (60ml) and called the peds pharmacy to ask if the dose was correct. The pharmacist double ask if the dose was correct. The pharmacist double checked the dose in CHIP and verified the dose was checked the dose in CHIP and verified the dose was correct. Together they decided to use a syringe pump correct. Together they decided to use a syringe pump to administer over 30 minutes rather than IV push. to administer over 30 minutes rather than IV push.
Shortly after, the patient began to experience arrhythmias. Shortly after, the patient began to experience arrhythmias. The drug was stopped, electrolytes monitored, and The drug was stopped, electrolytes monitored, and patient sent to the PICU. patient sent to the PICU.
Case Scenario #2Case Scenario #2
To Err is Human, To Fail is Swiss To Err is Human, To Fail is Swiss
Cheese?Cheese? Physician order doesn’t include concentration
Order Checked by Peds PharmacistIn 6th floor Satellite
Medication prepared in IVR on 4th Floor
Nurse calls 6th floor pharmacist and questions dose not volume
Medication administered to pt
Transformation to a Culture Transformation to a Culture of Safety of Safety
Academic Healthcare Academic Healthcare ExperienceExperience
““Common qualities shared by top Common qualities shared by top performers included a shared performers included a shared sense of purpose, a hands-on sense of purpose, a hands-on leadership style, accountability leadership style, accountability systems for quality and safety, a systems for quality and safety, a focus on results, and a culture of focus on results, and a culture of collaboration”collaboration”
Keroack at al. Keroack at al. Academic Medicine, Academic Medicine, 20072007
What Does Accountability What Does Accountability Look Like?Look Like?
Reasonable performance expectationsReasonable performance expectations Applied fairly, expectations similar for allApplied fairly, expectations similar for all Proportional consequencesProportional consequences Appropriate carrots and sticks used to drive Appropriate carrots and sticks used to drive
system to excellencesystem to excellence ““No blame” is dominant front line No blame” is dominant front line
cultureculture For innocent slips and mistakesFor innocent slips and mistakes
Clear demarcation of blameworthy actsClear demarcation of blameworthy acts E.g. gross incompetence, failure to heed E.g. gross incompetence, failure to heed
quality/ safety rules, disruptive behaviorquality/ safety rules, disruptive behavior
Theory to Practice: Theory to Practice: Required Elements Required Elements
Teamwork: dampen authority gradientsTeamwork: dampen authority gradients Leader: do introductions, explicitly welcome input Leader: do introductions, explicitly welcome input
from team members, debriefings after proceduresfrom team members, debriefings after procedures Communication: standardized format e.g. Communication: standardized format e.g.
SBARSBAR Decreased complexityDecreased complexity Independent checks need to be Independent checks need to be
“independent”“independent” Standardizing processes and practicesStandardizing processes and practices Report adverse events, learn from defectsReport adverse events, learn from defects
Theory to Practice: Theory to Practice: Required ElementsRequired Elements
Strong leadership and championsStrong leadership and champions One person’s empowerment is another’s One person’s empowerment is another’s
depowerment!depowerment! Buy-in from all: this is hard work!Buy-in from all: this is hard work! Support the folks who “speak up”: even Support the folks who “speak up”: even
when everything turns out to have been when everything turns out to have been fine!fine!
Become comfortable with “blame free”, Become comfortable with “blame free”, yet holding people accountable, as yet holding people accountable, as appropriate.appropriate.
WHO? Everyone - All Ghosts and Goblins!WHAT? Join the fun at our “Haunted Hospital” – Complete with Games, Displays, and GOODIES!
WHERE? Ruby – 4th Floor – Conference Rooms 3A/3B
WHEN? October 31, 2008 – 12p – 4p
November 1, 2008 – 6a – 10a
ConclusionConclusion
"You've got to be very careful if you don't know where you're going, because you might not get there."
Yogi Berra