Culture of Safety

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Culture of Safety

• HSC Faculty Development Program
• Niti Armistead, MD FACP
• October 30th, 2008

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Objectives

• Safety from a patients perspective
• Case scenarios from closer to home
• Science of safety
• Importance of teamwork and communication
• Theory to practice required elements

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Josie King

• Spot for video

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Audience Thoughts

• How could this story happen?
• Could this happen at any Healthcare facility,
  including WVUH?
• Does organizational culture have any role in
  this issue?

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Case Scenario 1

• Mr. Jones is a 89 year old man involved in a
  motor vehicle accident 1 month prior to
  admission. Over the month, he became
  progressively confused and lethargic. Head CT by
  PCP revealed a large left sided subdural
  hematoma. He was transferred to our facility for
  further evaluation and treatment.

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Case Scenario 1

• Upon admission to SICU, patients wife was
  consented for a left twist drill procedure for
  insertion of a drainage catheter. Dr Smith
  marked the site while the family was present in
  the room, while he was talking with them. Family
  left the room just prior to the procedure. RNs
  John and Susan were in and out of the room at
  various times. John was the stat nurse and Susan
  had another patient assignment. It was shift
  change and there was a lot of activity in the
  unit, including many visitors and calls.

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Procedure

• Dr Smith shaved a small spot on the scalp and
  prepped the area with chloraprep. He placed a
  drain on the right side of the head. There was
  no drainage noted. Immediately Dr Smith realized
  he had placed the drain on the wrong side. He
  successfully went on to place another drain on
  the left side.
• There is a space on the sedation form for the
  surgical pause and site validation. This space
  was left blank.
• Mr. Jones suffered no direct harm from the
  placement of either drain.

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Case Scenario 1

• How could this wrong-site procedure have been
  prevented?

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Science of Safety

• Late 1999, Institute of Medicine (IOM) published
  a report, To Err is Human Building a Safer
  Health System
• Estimated 44,000 to 98,000 deaths from errors
• Equivalent of a jumbo jet crashing each and
  every day in the U.S.
• Generally not an issue of bad apples
• Challenge build a system that catches the
  inevitable lapses of mortals1

1. Wachter, Shojania. Internal Bleeding. New
York, NY Rugged Land, 2004
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The Swiss Cheese Model of Safety
Layers of Protection
Some holes due to active failures
Hazards
Other holes due to system design
Error Reaches Patient
James Reason, Human error
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Science of Safety
All healthcare encounters
All errors
All adverse events
Preventable adverse events
Non-preventable adverse events
near miss
Negligent adverse events
Wachter. Understanding Patient Safety, McGraw
Hill, NY 2008
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Quality versus Safety for example

• Patient comes in to ED with chest pain. His EKG
  shows ST elevation, suggesting acute MI. He
  receives an aspirin and a beta-blocker and taken
  to the cath lab immediately. In the post
  procedure time, he receives his metformin and 2
  doses of ibuprofen. Patients hospital stay is
  complicated by acute renal failure.
• Acute MI quality process measures met? Yes. This
  is publicly reported and relatively easily
  measured.
• Was his safety optimized? No. This is not as
  easily detected!

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Science of Safety

• What does system-focused approach look like?
• Technology
• Practices
• Procedures
• Policies
• Culture!
• Culture collection of values, beliefs and
  assumptions that guide members behaviors

Pronovost et al, Implementing and Validating a
Comprehensive Unit-Based Safety program, Journal
of Patient Safety. March 2005
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Culture of Safety

• Culture the way we do things around here

 
Culture Eats Strategy for Lunch
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What is a Safe Culture?

• In a safe culture, employees are guided by an
  organization wide commitment to safety, in which
  each member upholds their own safety norms and
  those of their coworkers
• Aviation industry experience supports an
  association between culture and error management
• Teamwork training diverse crews to dampen steep
  and unyielding authority gradients
• Communication clear, timely, closed, structured

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Lessons from Other Industries
Aviation Industry
Toyota Model

• Preflight briefings and checklists
• Call-outs
• Standard procedures
• Terminology
• Mitigate error consequences
• Teamwork
• Leadership

• Every defect is learned in real time
• Production is stopped, Any one can stop the line!
  (gidoka)
• Defect is resolved and they learn from the defect
  (Kaizen)
• Eliminate waste (muda)

Anyone can stop the plane
Anyone can stop the line
Q has anyone done this in healthcare??? Yes!
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Johns Hopkins Experience Comprehensive
Unit-Based Safety Program

• CUSP 6 steps
• Evaluate-AHRQ Survey Tool
• Educate on science of safety
• Identify defects as a unit
• Adopt interventions
• Learn from defect and others
• Evaluate

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Johns Hopkins Experience Comprehensive
Unit-Based Safety Program

• Results
• Significant improvement in staffs perception
  about patient safety and safety climate.
• Several safety initiatives implemented e.g. ICU
  daily goals sheet and medication reconciliation
• Reduction in ICU nursing turnover
• Reduction in ICU length of stay

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Teamwork and Communication
Attending Surgeon
Anesthesiologist
Surgical RN
CRNA
Anesthesia Resident
Sexton et al. Errors, stress and teamwork in
medicine and aviation, BMJ 2000 320 745-749
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Teamwork and Communication

• All organizations need structure and hierarchies
• Taken to extreme, rigid hierarchies lead to
  frontline staff not speaking up
• Healthcare is different from aviation
• team is very heterogeneous training, income,
  status
• Come to expect a norm of faulty and incomplete
  exchange of information
• When in doubt, we default to it must be OK
• Need to change mindset to if youre not sure
  its right, assume it is wrong

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To Err is Human, To Fail is Swiss Cheese?
Site marking done while MD distracted
No X-ray confirmation
Environmental factors
Wrong site procedure
No time out conducted
No one said stop! Lets take a time out!
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Case Scenario 2

• Infant was ordered calcium gluconate for low
  calcium. MD entered order for calcium gluconate
  400 mg (100mg/kg) IV push. The peds pharmacist
  (working on 6th floor) checked the initial order
  and sent labels to the IV room (4th floor).
• The IV room tech drew up 40 ml (4000 mg), the
  dose was checked and sent to the floor.
• The nurse administering the doses was
  uncomfortable with the syringe size (60ml) and
  called the peds pharmacy to ask if the dose was
  correct. The pharmacist double checked the dose
  in CHIP and verified the dose was correct.
  Together they decided to use a syringe pump to
  administer over 30 minutes rather than IV push.
• Shortly after, the patient began to experience
  arrhythmias. The drug was stopped, electrolytes
  monitored, and patient sent to the PICU.

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To Err is Human, To Fail is Swiss Cheese?
Physician order doesnt include concentration
Medication prepared in IVR on 4th Floor
Order Checked by Peds Pharmacist In 6th floor
Satellite
Medication administered to pt
Nurse calls 6th floor pharmacist and questions
dose not volume
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Transformation to a Culture of Safety

Uniformity
Variations
Quality focus
Financial focus
Transparent
Restricted
Autocratic
Team
Practice focus
Patient centered
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Academic Healthcare Experience

• Common qualities shared by top performers
  included a shared sense of purpose, a hands-on
  leadership style, accountability systems for
  quality and safety, a focus on results, and a
  culture of collaboration
• Keroack at al. Academic Medicine, 2007

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What Does Accountability Look Like?

• Reasonable performance expectations
• Applied fairly, expectations similar for all
• Proportional consequences
• Appropriate carrots and sticks used to drive
  system to excellence
• No blame is dominant front line culture
• For innocent slips and mistakes
• Clear demarcation of blameworthy acts
• E.g. gross incompetence, failure to heed quality/
  safety rules, disruptive behavior

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Theory to Practice Required Elements

• Teamwork dampen authority gradients
• Leader do introductions, explicitly welcome
  input from team members, debriefings after
  procedures
• Communication standardized format e.g. SBAR
• Decreased complexity
• Independent checks need to be independent
• Standardizing processes and practices
• Report adverse events, learn from defects

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Theory to Practice Required Elements

• Strong leadership and champions
• One persons empowerment is anothers
  depowerment!
• Buy-in from all this is hard work!
• Support the folks who speak up even when
  everything turns out to have been fine!
• Become comfortable with blame free, yet holding
  people accountable, as appropriate.

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WVUH Haunted Hospital
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
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Conclusion
"You've got to be very careful if you don't know
where you're going, because you might not get
there." Yogi Berra