Errors: A Balance Between Learning and Accountability

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Errors A Balance Between Learning and
Accountability

• Presented to
• The Michigan Health and Safety Coalition
• April 14, 2004

David Marx, JD
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Lets be Honest
MEN
WOMEN
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Agenda

• An Introduction to Patient Safety and Just
  Culture
• Disciplinary Analysis
• The Just Culture
• Just Culture Implementation
• Questions

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An Introduction to Discipline

• There are activities in which the degree of
  professional skill which must be required is so
  high, and the potential consequences of the
  smallest departure from that high standard are so
  serious, that one failure to perform in
  accordance with those standards is enough to
  justify dismissal.
• Lord Denning
• English Judge

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An Introduction to Discipline

• People make errors, which lead to accidents.
  Accidents lead to deaths. The standard solution
  is to blame the people involved. If we find out
  who made the errors and punish them, we solve the
  problem, right? Wrong. The problem is seldom
  the fault of an individual it is the fault of
  the system. Change the people without changing
  the system and the problems will continue.
• Don Norman
• Apple Fellow

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An Introduction to Discipline

• The single greatest impediment to
• error prevention in the medical industry is
• that we punish people for
• making mistakes.
• Dr. Lucian Leape
• Professor, Harvard School of Public Health
• Testimony before Congress on
• Health Care Quality Improvement

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An Introduction to Discipline

• No person may operate an
• aircraft in a careless or reckless manner so as
  to endanger the life or property of another.
• Federal Aviation Regulations
• 91.13 Careless or Reckless Operation

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An Introduction to Discipline

• As far as I am concerned, when I say careless
  I am not talking about any kind of reckless
  operation of an aircraft, but simply the most
  basic form of simple human error or omission that
  the Board has used in these cases in its
  definition of carelessness. In other words, a
  simple absence of the due care required under the
  circumstances, that is, a simple act of omission,
  or simply
• ordinary negligence, a human mistake.
• National Transportation Safety Board
• Administrative Law Judge
• Engen v. Chambers and Langford

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NCSBN Model Nursing Practice Act

• IX. Discipline and Proceedings,
• e. Unsafe Practice/Unprofessional Practice
• Failure or inability to perform registered
  nursing, practical nursing, as defined in Article
  II, with reasonable skill and safety.
• 2. Unprofessional conduct, including a departure
  from or failure to conform to board standards of
  registered nursing, practical nursing, or
  advanced practice nursing.
• 6. Conduct or any nursing practice that may
  create unnecessary danger to a clients life,
  health or safety.

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An Introduction to Discipline
 
In Washington, there were disciplinary actions
reported against 408 doctors including 11 who
were disciplined for substance abuse, 25 for
misprescribing or overprescribing drugs, 28 for
sexual abuse of or sexual misconduct with a
patient, 55 for substandard care, incompetence or
negligence and 9 who were convicted of a crime.
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The Tension

• To improve patient safety, we must make better
  use of minor human error events
• The threat of corporate disciplinary action and
  regulatory enforcement is a major obstacle to
  event reporting and investigation
• The role of disciplinary action must be addressed

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Disciplinary Decision-Making
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The Four Evils?The Words You Use Today
Negligent Behavior (carelessness)
Reckless Behavior (gross negligence)
KnowingViolations
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Distinguishing Negligent and Reckless Behavior

• Negligence
• Should have been aware of a substantial and
  unjustifiable risk
• Equivalent to social definition of human error
• A compensatory concept in the law

• Recklessness
• Conscious disregard of a substantial and
  unjustifiable risk
• A punitive concept in the common law

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The Just Culture
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The Human Reliability Curve
100
Human Error
Human Reliability
Successful Operation
0
Poor
Good
Factors Affecting Human Performance (including
personal behaviors)
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Managing Risk The Three Behaviors

• Manage through
• Understanding our at-risk behaviors
• Removing incentives for at-risk behaviors
• Creating incentives for healthy behavior
• Increasing situational awareness

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A Just Culture

• A Set of Beliefs
• A recognition that professionals will make
  mistakes
• A recognition that even professionals will
  develop unhealthy norms
• A fierce intolerance for reckless conduct

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A Just Culture

• A Set of Duties
• To raise your hand and say Ive made a mistake
• To raise your hand when you see risk
• To resist the growth of at-risk behavior
• To participate in the learning culture
• To absolutely avoid reckless conduct

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Implementing a Just Culture
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Create a Safety-Supportive Policy
HOSPITAL WIDE POLICY Policy 6.350 Page 1
of 3 Origination Date 5/03 Reviewed 6/03 Revis
ed SUBJECT NON-PUNITIVE CULTURE PURPOSE To
encourage reporting of adverse medical events,
near misses, existence of hazardous conditions,
and related opportunities for improvement as a
means to identify systems changes which have the
potential to avoid future adverse events. To
provide guidelines for the application of
non-punitive processes versus disciplinary
actions. POLICY PVHMC encourages reporting of all
types of errors and hazardous conditions. The
organization recognizes that if we are to succeed
in creating a safe environment for our patients,
we must create an environment in which it is safe
for caregivers to report and learn from
errors. It is recognized that competent and
caring associates may make mistakes and it is the
intention not to instill fear or punishment for
reporting them. There must be a non-punitive,
supportive environment for all staff to report
errors and near misses. Error and near miss
reporting are a critical component of the PVHMC
patient safety and risk management
program. Errors and accidents should be tracked
in an attempt to determine trends and patterns to
learn from them and prevent a reoccurrence, thus
improving patient safety. The focus is on how
systems and processes can be improved to help
people avoid mistakes in the future In the
process of evaluating errors and near misses,
healthcare providers participate in reporting and
developing improved processes GUIDELINES The
focus of the program is performance improvement,
not punishment. Employees are not subject to
disciplinary action when making or reporting
errors/injuries/near misses except in the
following circumstances The employee repeatedly
fails to participate in the detection and
reporting of errors/injuries/near misses and the
system-based prevention remedies. There is reason
to believe criminal activity or criminal intent
may be involved in the making or reporting of an
error/injury. False information is provided in
the reporting, documenting, or follow-up of an
error/injury. The employee knowingly acts with
intent to harm or deceive. Reckless acts

• State the Purpose
• Draw the Bright Line
• Set the Expectations

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Modify Your Toolset

• Safety-oriented event investigation
• Explain every error
• Explain every violation
• What do events say about future risk
• Begin thinking prospectively
• Chronic unease
• Failure Modes and Effects Analysis
• Probabilistic Risk Assessment
• Proactive At-Risk Behavior Analysis

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Train the Management Team(an example curriculum)

• Just Culture and Patient Safety
• An Intro to Human Error
• Managing Normal Error
• Managing At-Risk Behavior
• Managing Reckless Behavior

• Event Reporting and Investigation
• The Investigation Process
• The Role of Peer Review
• Making System Changes

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Conclusion
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Even the best of us are going to make mistakes
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its our response that will make the difference

• It is more of what we teach our kids
• An expectation that errors will be reported
  (transparency)
• No expectation of perfection
• Accountability for choosing to take risk
• Expectations set at system level
• Expectation that system safety will improve

• It is not Hammerhead (or Whack-a-Mole)

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Questions?