30
Culture of Culture of Safety Safety HSC Faculty Development HSC Faculty Development Program Program Niti Armistead, MD FACP Niti Armistead, MD FACP October 30 October 30 th th , 2008 , 2008

Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

Embed Size (px)

Citation preview

Page 1: 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

Page 2: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 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

Page 3: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

Josie King Josie King

Spot for videoSpot for video

Page 4: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

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?

Page 5: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

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.

Page 6: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

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.

Page 7: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

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.

Page 8: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

Case Scenario #1Case Scenario #1

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

Page 9: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

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

Page 10: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

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

Page 11: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

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

Page 12: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 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!

Page 13: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

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

Page 14: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

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

Page 15: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

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

Page 16: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

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)

Page 17: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

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

Page 18: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

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

Page 19: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

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

Page 20: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

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”

Page 21: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

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!”

Page 22: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

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

Page 23: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

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

Page 24: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

Transformation to a Culture Transformation to a Culture of Safety of Safety

Page 25: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

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

Page 26: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

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

Page 27: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

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

Page 28: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

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.

Page 29: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

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

Page 30: Culture of Safety HSC Faculty Development Program Niti Armistead, MD FACP October 30 th, 2008

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