04/13/2023 1

Science of Safety Training

Presented by Krish Sankaranarayanan MS, MBA, CPHQSenior Safety Officer

Introduction-About me

• Been in healthcare domain for over 24 years.• Triple Masters degree.• MS in Patient Safety Leadership from UOI-

Chicago.• Certified Professional in Healthcare Quality

(CPHQ)• Educational consultant- Canadian Healthcare

Association- CQI program• Membership

– Member American College of Healthcare Executives– Member National Association of Healthcare Quality – Member American Society for Healthcare Risk Management – Member American Society of Professionals in Patient Safety– Vice President of the ACHE Middle East and North Africa Group

04/13/2023 3

Discussion Items

• Ice Breaker- Eric Cropp story (Video)• Historical context of Patient Safety?• Second Victim• Comprehensive Unit-based Patient Safety

program- Josie King Story (Video)• Learning from defects• Celebrating Safety• 2-Question Survey

04/13/2023 4

04/13/2023 5

Aftermath of an error Shame & Blame

04/13/2023 6

Medical error: the second victim..

• The term second victim was initially coined by Wu in his description of the impact of errors on professionals. The doctor who makes the mistake needs help too.

• In the aftermath of a mistake, it's important the doctor seek support to deal with the consequences.

Albert W Wu associate professorSchool of Hygiene and Public Health and School of Medicine, JohnsHopkins University, Baltimore, MD

The Annual Toll of Medical Injury

IOM “To Err is Human” (1999)

• 44,000 – 98,000 deaths/year in US due to medical errors.

• $ 50 billion in total costs.• 7% of patients suffer a medication error.• Every patient admitted to ICU suffers an

adverse event.

Where we stand?

The patients saw an average of 17.8 health professionals during their hospitalizationHow many health professionals does a patient see during an average hospitalstay? N Whitt, R Harvey, S Child

04/13/2023 14

04/13/2023 15

Building a Culture of Safety

What is Culture*?:

“The way we do things around here”

1 attitude = opinion…everyone’s attitude = culture

*aka Climate

“Culture is local” and “so is change.”

Definition • Safety culture is the ways in which safety is managed in the workplace,

and often reflects "the attitudes, beliefs, perceptions and values that employees share in relation to safety" (Cox and Cox, 1991).

• The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization's health and safety management. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures. (AHRQ)

• Source: Organising for Safety: Third Report of the ACSNI (Advisory Committee on the Safety of Nuclear Installations) Study Group on Human Factors. Health and Safety Commission (of Great Britain). Sudbury, England: HSE Books, 1993.

Safety Culture in High Reliability Organizations- HRO’s

Early adopters- Aviation

04/13/2023 21

Josie King Story

04/13/2023 22

04/13/2023 23

Culture in safe organizations• Commit to no harm • Focus on systems not people• Value Communication/teamwork

– Assertive communication– Teamwork– Situational awareness

• Accept responsibility for systems in which we work• Recognize culture is local• Seek to expose (not hide) defects • Celebrate safety

– Workers viewed as heroes

Johns Hopkins Comprehensive Unit-based Safety Program (CUSP)

CUSP is a 6-step safety programStep 1: Safety Attitude Questionnaire (SAQ) Step 2:Staff education on the Science of SafetyStep 3: 2-item Staff Safety Survey

▪ Please describe how you think the next patient in your unit/clinical area will be harmed?

▪ Please describe what you think can be done to prevent or minimize this harm?

Step 4: Executive Walk RoundsStep 5: a) Learning from our mistakesb) Improve teamwork and communicationStep 6 : Resurvey staff about Safety Culture (annually)

04/13/2023 25

How we started at Tawam?

• January-08 Created the Patient Safety dept. recruited 4 patient safety officers and a medication safety officer.

• February-08 Leadership training on Patient Safety• April-08 Comprehensive Unit based Safety Program

Roll-Out. • 2008- ICU, NNU, Peds Onc (Pilot Units)• 2011- Medical 1 & 2, Surgical 1& 2, Daycase, PICU• 2012- OBGYN• 2013- OR & ED

Greatest Challenge at Tawam

• Employees hail from 60 nations• Hierarchies between providers • A culture that isn’t accustomed to

acknowledging medical errors.• Tendency for poor communication and

teamwork that lead to adverse events.

Tawam had a history-“you made a mistake, and you’re terminated.”

Measuring Culture of Safetytested and well known tools

• Safety Attitudes Questionnaire • Patient Safety Culture in Healthcare

Organizations • Hospital Survey on Patient Safety Culture • Safety Climate Survey • Manchester Patient Safety Assessment

Framework

28

Baseline assessment-Safety Attitudes Questionnaire

Culture of Safety Survey- Domains1. Teamwork Climate2. Safety Climate3. Job Satisfaction4. Stress Recognition5. Working Conditions6. Perceptions of Hospital Management7. Perceptions of Unit Management

Dependent Variables of SAQ

• The primary dependent variables -teamwork climate and safety climate scale scores.

• These primary dependent variables were chosen because they are important in preventing patient harm.

• The rest of them are secondary dependent variables.

Sexton J.B., et al.: The Safety Attitudes Questionnaire: Psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res 6(44):Apr. 3, 2006.Timmel J, Kent PS, Holzmueller CG, Paine L, Schulick RD, Pronovost PJ. Impact of the Comprehensive Unit-Based Safety Program (CUSP) on safety culture in a surgical inpatient unit. Jt Comm J Qual Patient Saf 2010;36(6):252-260.

Location YearTargeted staff

Surveys Administered

SurveyReturned

Surveyresponse rate

Phase 1 CUSP Pilot Units 2008 199 199 199 100%

Phase 2 In-patient areas 2010 1600 1476 1450 98%

Phase 3Out-Patient & satellite locations

Qtr 42011 805 497 483 60%

Total 2604 2172 2132

82% of staff in patient care areas have participated in the overall 3 phases of SAQ Survey.

81% overall response rate in all the 3 phases of SAQ Survey.

Safety Attitude Questionnaire-(SAQ)

2008 SAQ Phase-1 (CUSP Pilot Units)

Team

work

Safet

y

Job

Satisf

actio

n

Stress

Rec

ogni

tion

Perce

ptio

ns o

f Hos

pita

l Man

agem

ent

Perce

ptio

ns o

f Uni

t Man

agem

ent

Wor

king

Condi

tions

0%

20%

40%

60%

80%

100%

SAQ Results 2008

ICUPediatric OncologyNNU

Domain

Av

era

ge

% P

os

itiv

e

2010 SAQ Phase-2 (All In-patient Units- & CUSP Pilot Units Re-survey)

2011 SAQ Phase-3 (Out-patient Units)

04/13/2023 34

Leadership Assigned to Twelve CUSP units

CUSP is a leadership driven &

Partnership driven program

Stakeholders & Team

2 question survey: CUSP Expansion Pilot Units- 2008

• Please describe how you think the next patient in your unit/clinical area will be harmed. • Please describe what you think can be done to prevent or minimize this harm.

Communica-tion &

Teamwork

Staffing Medication Errors

Infection Control

Policies & Procedures

Education Equipment Others0%

5%

10%

15%

20%

25%

30%

2-item Staff Safety Survey

ICU N=93NICU N=73Peds Onc N=39

Areas of concern

2 question survey: CUSP Expanded Units- 2010 & 11

• Please describe how you think the next patient in your unit/clinical area will be harmed. • Please describe what you think can be done to prevent or minimize this harm.

Communication/Teamwork

Staffing

Medication Errors

Infection Control

Policies/Procedures and systems

Education

Equipment/Environment/facilities

Other

0% 10% 20% 30% 40% 50% 60%

2-Question survey

ObgynSurg 2Surg 1DaycaseMed 2Med 1

39

Peds Oncology - CUSP Meeting Peds Oncology - CUSP Meeting

NNU- CUSP Meeting ICU- CUSP Meeting

Steve Talking to the House Keeping staff

ICU- CUSP Executive Walk rounds

Peds Oncology - CUSP Executive Walk rounds

Culture linkages to Clinical, Operational & other Outcomes

• Wrong Site Surgeries• Decubitus Ulcers • Delays• Bloodstream

Infections• Post-Op Sepsis• Post-Op Infections• Post-Op Bleeding• PE/DVT• RN Turnover• Absenteeism• VAP

• Burnout• Unit size• Communication

breakdowns• Familiarity• Spirituality• Most validated:

Qual. Saf. Health Care 2005;14;364-366

42

ICU CLABSI Free Days

CUSP Team with the ICU Executive - COO

43

NNU CLABSI Free Days

44

“I Watch The Line”- Campaign

• To increase staff awareness • To ensure staff active involvement• To ensure conscientious implementation

ICU NNU PICU

45

CLABSI Free Days

• ICU– 323 CLABSI free days until 25th Dec 2012– Recounting -42 CLABSI free days until 5th

February.– Recounting -23 CLABSI free days until 28th

Feb.• NNU-183 days until 28th Feb.• PICU- 115 days until 28th Feb.

04/13/2023 46

“Insanity: doing the same thing over and over again and

expecting different results”Albert Einstein

04/13/2023 47

“Every system is perfectly designed to achieve the results it gets.”

Donald Berwick, M.D.

04/13/2023 48

Not Bad people - But Bad Systems

04/13/2023 49

What can we do to improve?

Errors can be prevented by designing systems that make it hard for people to do the wrong thing, and easy for people to do the right thing.

04/13/2023 50

Critical thinking!!!

04/13/2023 51

System redesign

04/13/2023 52

System Design- Forcing Function

04/13/2023 53

Error Prevention

• “Smart people learn from their own mistakes, wise people learn from other's mistakes.”

04/13/2023 54

Formula 1 Pit stop

04/13/2023 55

Formula 1 Pit stop• Takes six to twelve seconds in duration.• Every pit stop is filmed and monitored by

human factor experts• Errors are scored in five levels• Highest score goes to the smallest error,

because people are unaware of it.

04/13/2023 56

Aviation-Sterile cockpit rule

• Prohibits crew member performance of non-essential duties or activities while the aircraft is involved in taxi, takeoff, landing, and all other flight operations conducted below 10,000 feet, except cruise flight.

• Prohibits the personal use of a personal wireless communications device or laptop computer while a flight crew member is at duty station during all ground operations

04/13/2023 57

When errors occur one of the three things happen

• It can cause the person to become a championOr • It can cause the person to leave the profession

prematurely Or• It can make the person go in to a shell and feel

completely withdrawn and Disengaged.

04/13/2023 58

Medication Error Story-1

Double check for expiration date

not done properly

First Nurse proceeded to

administer the vaccine without

taking the tablet PC to the patient bed

side

Vaccine Injected and asked second Nurse to chart in

Cerner on his behalf

Second Nurse baffled after seeing the expiration date and the missing expiration

date in the label

Error reached the patient but did not cause harm

Expired vaccine arrived from

Pharmacy

SWISS CHEESE MODEL

04/13/2023 59

Medication Error Story-2

Chemotherapy Written by MD.

Vincristinedoxorubicin

And l_aspargenes

Checked according

To the protocolThen faxed

to pharmacy

Prepared by Pharmacy

MedicationReceived from

Pharmacy ,Checked with

Another Chemotherapy

Competent NurseVCR

DOXOL-Asp

Two medication taken to

patient roomVCR and

DOXOAnd

Emla cream

L-Asp returned to fridge

04/13/2023 60

Medication Error Story-3

What Happened

• Remicade a non formulary was administered to the patient (order was in paper)

• Premedication of antihistamine, panadol was ordered in CERNER which was not communicated to the nurse

• The patient developed allergic reactions

What Next• Investigation revealed that there was no set

protocols or guidelines• Break down in communication & information

transfer

Action• Guidelines, protocols and checklist were

developed • No incidents since then

04/13/2023 61

Implication of the errors

• The staff came open and reported the incidents• Since CUSP was in place it helped institute a Fair and

Just Culture• Investigation of the incidents, examined the

processes and not just people.• The three nurses shared their experiences with other

CUSP units. • The three nurses have now become our patient

safety champions.

Broke the myth-“you made a mistake, and don’t get terminated.”

04/13/2023 62

Learning from Defects- Tawam

• Creation of Safety Event Analysis Teams in each CUSP unit.– Identified a team of believers – Team identified defects from Patient Safety Net

(PSN) – Implemented systems changes to reduce the

probability of recurring.– At least one defect was investigated each month.

63

Impact of CUSP on the staff

CUSP Can turn ordinary people in to champions

Best Catch Award program

Celebrating Safety – Viewing workers as heroes• Instituted in 2009 for the best near miss caught. • Now in the fourth year of implementation.• Provided opportunity for staff to proactively identify

and implement risk reduction strategies.• 2010, 2011 & 2012 Best Catch awards went to CUSP

units.

04/13/2023 65

Best Catch Award 2010Pediatric Oncology- CUSP

Abdulla Odat RN receives the award from the COO Mr. Steve Matarelli and ICQO

Ms. Ahlam Al Sheiban

Synopsis :Chemotherapy IFOSFAMIDE per protocol is for four doses, and it was written for 5 days.

The fifth dose arrived , nurse checked protocol and prevented.

Systemic change :A copy of the protocol in pharmacy and patient chart to double check and prevent errors.

Prevented excess dose of Chemotherapy medication

Best Catch Award 2011ICU- CUSP

Rhian EvansAssociate Nurse Manager – ICU receives the award from the CEO

Mr. Gregory Schaffer

Synopsis :

Cauterization (ritualistic burning) Prevented family from approaching patient on ventilator with hot burning coal in patient room. Coal was extinguished safely. Resulted in system and policy changes.

Prevented cauterization and accidental fire in the ICU

04/13/2023 67

Best Catch Award 2011NNUCUSP

Asuncion CarlosSr. Respiratory Therapist -

receives the award from the CEO Mr. Gregory Schaffer

Synopsis :

An inappropriate order for heliox therapy for NNU patient was not carried out.

Prevented inappropriate order for therapy

04/13/2023 68

Best Catch Award 2012Peds Oncology CUSP

Synopsis

The physician had ordered Metototrexate IT for this patient. In OR the mother of the patient told the nurse that the patient should receive Cytarabin IT, not Metotrexate. The Physician had prescribed the wrong drug.

Iiris PietikainenSenior Charge Nurse/Unit Manager Peds

Oncology

Prevented administration of wrong chemotherapy medication

Arab Health Awards

• Tawam’s patient safety initiatives were shortlisted for Arab Health in 2010 and 2011 awards and bestowed “commendable.”

Dr. Prathap C Reddy’s Safe Care Awards 2011 India –Judging Panel

Dr Pranav MehtaVP Physician & Ambulatory Care Services, North Shore Long Island Jewish Healthcare System & Examiner of prestigious National Malcolm Baldrige Quality Award

Ms. Diane C. PinakiewiczPresident-National Patient Safety Foundation

Ms. Manisha Shah VP -National Patient Safety Foundation

Ms Ann JacobsonExecutive Director International Accreditation, JCIA

Dr Cyrus EngineerManager, WHO Patient Safety project, Johns Hopkins

Award being received from the Chief Minister of the Indian State of

Andhra Pradesh

His Excellency Nallari Kiran Kumar Reddy, Hon'ble Chief Minister of Andhra Pradesh standing fourth from left, gives away the award. Also present Diane C. Pinakiewicz President NPSF and Dr Prathap C Reddy, M.D, MBBS, FCCP, FICA, FRCS Apollo Hospital Group India

Awarded to Tawam Hospital for the project title- Establishing “Culture of Safety”-A UAE Hospital Experience

04/13/2023 72

Presented in conferences1. Speaker at the Patient Safety Congress–IIRME Abu Dhabi- October 2009.2. Speaker at the ICHA Convention for Patient Safety -New Delhi India- October 20093. Speaker at the Healthcare Management Forum -IIRME Dubai- January 2010.4. Submitted poster at the International Forum on Quality and Safety in Healthcare at Nice-April 2010.5. Submitted poster at the Patient Safety Congress in UK-May 2010.6. Speaker at the Quality Standards and Accreditation Conference at Dubai -June 2010.7. Presented poster at the 13th International Conference on Emergency Medicine at Singapore-June 2010.8. Speaker at the Safety 2010 World Conference at UK- September 2010.9. Speaker at the Patient Safety Congress–IIRME Abu Dhabi-October 2010.10. Speaker at the International Patient Safety Conference-AIIMS New Delhi-October 2010.11. Speaker at the Healthcare Management Forum -IIRME Dubai- January 2011.12. Speaker at the First International Conference on Patient Safety -Oman-February 2011.13. Speaker at the KFSHD -Quality and Safety Event –Saudi Arabia-April -2011.14. Speaker at the Patient Safety Congress- Best Practices for Asia- India-April 2011.15. Speaker & Organizer of 2nd Tawam’s Patient Safety Conference- Al Ain- June 2011.16. Speaker at the at the XIX World Congress on Safety and Health at Work- Turkey- Sep 2011.17. Speaker at the 3rd Johns Hopkins Medicine Annual Patient Safety Summit- Baltimore USA- June 201218. Speaker by Tel-Conference at the URMPM WORLD CONGRESS -UK, Sep 2012. 19. Presented poster at the 5th Medication Safety Conference-Abu Dhabi-Nov 2012.20. Speaker at the 2nd Drug Safety MENA Summit-Abu Dhabi-February 2013.21. Member Scientific Advisory Board and Speaker at the Patient Safety & Quality Congress Middle East- Abu Dhabi- March 201322. Speaker at The 15th Annual NPSF Patient Safety Congress- USA- May 2013

04/13/2023 73

Culture of Safety is a journey

• It takes as long as 5 years to develop a culture of safety that is felt throughout an organization. (Ginsburg et.al 2005)

• Need Patience, Perseverance, Commitment & Engagement.

Thank You

04/13/2023 75

2-question Survey

• Please describe how you think the next patient in your unit/clinical area will be harmed?

• Please describe what you think can be done to prevent or minimize this harm?