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Creating a Culture of Patient Safety


Creating a Culture of Patient Safety – PowerPoint PPT presentation

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Title: Creating a Culture of Patient Safety

Creating a Culture of Patient Safety
  • Wheat Plains Health Network
  • Critical Access Hospitals

  • Definition of Safety Culture
  • Background
  • Characteristics of a Safety Culture
  • Making the case for a Patient Safety Culture
  • Creating the culture/Using your toolbox
  • Challenges
  • AHRQ Survey
  • Takeaways

Goals and Objectives
  • Understand the five key principles of
    reliability science
  • Describe the characteristics of a patient safety
  • Describe actions to create a culture of patient
  • Identify implementation challenges unique to
    culture change

What is culture?
  • Are these the right clothes to wear to work?
  • Should I bring my lunch to this staff meeting?
  • Who do I tell about this event?
  • Culture is
  • the way we do things around here

Definition of a safety culture
  • Institute for Healthcare Improvement (IHI)
  • A culture of safety is an atmosphere of mutual
    trust in which all staff members can talk freely
    about safety problems and how to solve them,
    without fear of blame or punishment essential
    to improving patient safety in any organization.

Definition of a safety culture
  • The National Patient Safety Agency (NPSA)
  • A safety culture in health care is one where
    staff and organization have a constant and active
    awareness of the potential for things to go
  • In a safety culture, both staff and leadership
    are able to acknowledge mistakes, learn from
    them, and take action to put things right.

Patient Safety Culture
  • A culture that puts safety first the number one
    priority, ahead of productivity and efficiency
  • A safety culture must be in place for patient
    safety practices to be truly successful

  • Patient Safety Culture has it roots in
    Reliability Science
  • High risk industries
  • Military Operations Cuban Missile Crisis
  • NASA -Challenger
  • Nuclear Power Plants Three Mile Island,
  • FAA Air Traffic Controllers Study (1979)
  • Health Care Organizations - To Err is Human (The
    IOM report, 1999)

To Err Is Human Building a Safer Health System
  • Released in 1999
  • 44,000 to 98,000 people die due to preventable
  • Eighth leading cause of death in the United
  • Regardless of the debate about the estimates,
    they remain the standard for describing the

Fallout of To Err is Human
  • Many organizations have endorsed use of
    patient-safety indicators
  • The Joint Commission
  • National Quality Forum
  • Leap Frog Initiative
  • Institute for Healthcare Improvement (IHI)
  • National Patient Safety Foundation
  • Agency for Healthcare Research and Quality (AHRQ)
  • CMS National Patient Safety Initiative
  • Legislation passed in 2003 and 2004 intended to
    increase the reporting of medical errors
  • Numerous documentaries, professional and lay
    press publications, PBS Mini-series
  • Increase in public awareness as to the hazards of

Framework of Reliability Science
  • Five Core Principles
  • Sensitivity to Operations
  • Reluctance to Simplify
  • Preoccupation with Failure
  • Deference to Expertise
  • Resilience
  • Implementation of these core principles leads to
    an overall state of mindfulness

Sensitivity to Operations
  • Constant awareness to the state of the system
  • Situational awareness
  • Operations are king small deviations in
    processes get full attention
  • Note risks
  • Prevention

Reluctance to Simplify
  • Simple processes are good
  • Reluctance to accept simple explanations can be
  • E.g. Lack of communication, training, staff
  • Essential to know true reason why patients are
    placed at risk

Preoccupation with Failure
  • Near Misses Opportunity for system improvement
  • Strengths
  • Weaknesses
  • Reduce potential for harm
  • Devotion of resources for improvement

Deference to Expertise
  • Organizational leaders defer to person with most
  • Situational decision making authority migrates
    based on the situation at hand
  • Issue relevant
  • De-emphasizes hierarchy

  • Expect failure in unanticipated ways
  • Develop capability to detect, contain and bounce
    back when errors do occur
  • Function despite setbacks
  • Prepare
  • Assessment
  • Contain
  • Improvise

  • Collectively , these core principles engage a
    constant state of mindfulness
  • Consistently safe, high quality care
  • Results in highly reliable systems

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Discussion Questions
  • What principles of a high reliability
    organization were used in this scenario?
  • What principles of a HRO were not used in this
  • Rewrite the scenario using principles of a HRO

Creating a Patient Safety Culture
  • Characteristics of this culture
  • Why embrace this culture
  • When do we start
  • Where do we start

Characteristics of a Patient Safety Culture
  • Just Culture
  • Perception of fairness and blamelessness
  • Flexible Culture
  • The ability to adapt
  • Reporting Culture
  • The willingness to report mistakes
  • Learning Culture
  • Learning from mistakes
  • Informed Culture
  • Information flow

Figure 1. Based on Reason (1997) The Components
of Safety Culture Definitions of Informed,
Reporting, Just, Flexible and Learning Cultures
Just Culture
  • It is irrational to expect individual workers to
  • flawlessly in defective organizations. No matter
  • how good our staff members are, everyone makes
  • mistakes. They suffer from a condition called
  • being human. Systems are too complex to expect
  • merely amazing people to perform perfectly 100
  • percent of the time no matter how hard they try.
  • Given that the vast majority of errors are due to
  • failures of bad systems and not bad people,
  • support to clinicians and other staff at the
  • sharp end of medical care is simply the
  • and compassionate thing to do. (Conway, 2009)

Defining the borders of bad behaviors (From P.
Stastny Sixth GAIN World Conference, Rome, 18-19
June, 2002)
Defining the borders of bad behaviors (From P.
Stastny Sixth GAIN World Conference, Rome, 18-19
June, 2002)
Types of Behavior Involved in Error
Behavior Type Definition
Human Error Unintentional action
At-Risk Behavior Unsafe habits
Reckless Behavior Substantial and unjustifiable risk
Intentional Rule Violation Willful disregard for the rules
Source Marx, 2001
From Reason (1997) A decision tree for
determining the culpability of unsafe acts.
p209From Reason (1997) A decision tree for
determining the culpability of unsafe acts. p209
Characteristics of a Patient Safety Culture
  • Patient Safety Cultures exist to the extent that
    there exists
  • Open communication
  • Feedback communication about error
  • Frequency of events reported
  • Effective handoffs transitions
  • Management support for patient safety
  • Blame free environment
  • Supervisor/manager expectations actions promote
    patient safety
  • Teamwork across units
  • Teamwork within units
  • Organizational learning
  • Overall perception of patient safety
  • Adequate staffing

Open Communication
  • The message of patients safety must be well
    conceived, repeated and consistent across the
    entire organization.
  • The organization openly discusses patient safety
    at all levels and seek mechanisms to foster such
  • The organization strive to include patients as
    active participants in their care and promote
    patient and family questioning aspects of care.
  • The organization discloses information about
    errors that reach a patient to the patient and
  • The governing board in informed of errors,
    safety problems and efforts to improve.

Feedback and Communication about Error
  • Staff informed about errors
  • Staff are given timely feedback
  • Changes that are implemented are communicated to
    all levels
  • The organization discusses ways to prevent errors

Frequency of Events Reported
  • Mistakes of the following types are reported
  • Mistakes caught and corrected before affecting
    the patient
  • Mistakes with no potential to harm patient
  • Mistakes that could harm patient, but do not

Effective Handoffs and Transitions
  • Important patient care information is transferred
  • Across hospital units
  • During shift changes

Management Support for Safety
  • Hospital management provides a work climate that
  • Promotes patient safety
  • Makes patient safety a top priority

Blame-Free Environment
  • The organization seeks to develop human resource
    and medical staff policies that support that most
    errors are a result of flawed systems.
  • Develops ways of rewarding rather than
    discouraging the reporting of errors.
  • Celebrates success at improving the reporting and
    use of reports to improve care delivery.
  • The organization seeks to engender an environment
    where reporting errors is the norm, without fear
    of retribution.
  • Implements methods of feedback to learn from

Supervisor/Manager Expectations Actions Promote
Patient Safety
  • Consider staff suggestions for patient safety
  • Praise staff for following patient safety
  • Do not overlook patient safety problems

Teamwork Across Units
  • Cooperation outside the unit
  • Coordination between units
  • End goal is to provide the best patient care

Teamwork Within Units
  • Staff support one another
  • Treat each other with respect
  • Work together as one team

Organizational Learning
  • Continuous Improvement
  • The organization recognizes the weaker aspects of
    performance and works to design error out and
    safety into workplace processes PROACTIVELY.
  • Seeks to reduce variation on delivery of care
    (protocols, checklists and standardization).
  • Evaluates the number of steps, hand-offs and
    persons are involved in carrying out specific
    processes (LEAN Methodology).
  • Looks to research and outside their own
    organization to reduce the possibility of errors
  • Methodically evaluates vulnerabilities of
    current care, new processes and new technology
    for threats to patient safety
  • Promotes an environment where mistakes lead to
    positive changes
  • Change is evaluated for effectiveness

Overall Perceptions of Patient Safety
  • Procedures and systems are good at preventing
  • General lack of patient safety problems
  • Incorporates accountability for patients safety
    into employee position descriptions and medical
    staff activities.
  • The organization discuss the importance of
    patient safety, surveillance and expectations for
    reporting patient safety concerns and errors with
    all employees, beginning at orientation.
  • Evaluates employees on contributions made towards
    patient safety.
  • The organization institutes team training and
    simulation for physicians and employees. Members
    of the team look out for one another, noticing
    errors before they cause an accident.

Adequate Staffing
  • Enough staff to handle workload
  • Work hours are appropriate to provide the best
    care for patients

Characteristics of an Organization With a
Commitment to Safety
  • Management must manage for patient safety just
    as they manage for efficiency and profit
    maximization. And safety must become part of
    what a hospital or health care organization
    prides itself on.
  • Lucian L. Leape, M.D.
  • Harvard School of Public Health

  • Mary Merchant, a RN who has been working
    with infectious disease patients for 15 years, is
    recognized as competent, careful and caring. She
    has supervisory and planning duties as well as
    her regular caseload, currently, five patients.
    Like most of her colleagues, Mary has a busy life
    outside her work. Today, she has an appointment
    with her sons teacher to discuss his behavioral
    problems, so she hopes she wont be asked to do a
    double shift.
  • Donnie Smith in Room 202b was admitted
    for treatment of pneumonia and is receiving IV
    antibiotics. As the last dose finishes, Mary goes
    to the medication room off the nurses station to
    get some heparin flush to clear the IV. Several
    days ago, one of the meds rooms overhead
    fluorescent lights went out and maintenance
    hasnt gotten to it yet to fix it.
  • Mary reaches into the drawer where the
    heparin flush is kept and pulls out a vial. Its
    hard to see it in this light, but she does this
    so many times a day its become a mechanical
    process. Marys thoughts drift to her meeting
    this afternoon at school whats going on with
    her son and whats shes going to do. She finds
    herself in the medication room wondering why she
    came in there in the first place. She suddenly
    remembers. The heparin for Mr. Smith.
  • As she picks up the vial, Dr. Grendle
    taps on the medication room window and asks her
    to join him for lunch. She says sure while
    wiping the top of the vial with an alcohol swab.
    She turns the vial upside down and draws out the
    liquid into the syringe. She puts the vial onto
    the counter and heads towards Mr. Smiths room.
  • As Mary is disconnecting the empty
    antibiotic container from the IV and flushing the
    line, Mr. Smith complains that the flush stings
    much more than the antibiotic did. Mary says it
    will stop in a few seconds. A minute later Mr.
    Smith slumps over in the bed in cardiac arrest.
  • After her patient has been attended to,
    Mary rechecks the vial it is not heparin flush,
    but concentrated potassium chloride in a vial
    similar in size and shape to the heparin. Looking
    from the top, one cant tell the difference
    between the two.

Discussion Questions
  • Use Reasons decision tree to determine if Mary
    is culpable in this incident.
  • What dimensions of a patient safety culture were
    present in this scenario?
  • What dimensions of a patient safety culture were
    not present in this scenario?


WHY a Safety Culture?
  • Improved outcomes
  • IOM report more people die from preventable
    medical mistakes than from AIDS, breast cancer or
    car accidents
  • Health care is more dangerous than nuclear power,
    airlines, driving,
  • Health care is as dangerous as bungee jumping
  • Decrease never events for which care will no
    longer be reimbursed

  • Making the case
  • Jury awards 4.7 million for failure to
    administer calcium after thyroidectomy

Why Building the Business Case
  • Cincinnati Childrens Hospital
  • Matched-case design
  • Increased patient satisfaction
  • Increased revenues by 17 annually
  • Preventing complications and HAIs
  • Reduced ALOS
  • Freed beds for sicker patients with higher
    reimbursement rates
  • Increased local and non-local demand for services

Iceberg of IgnoranceThe of organizational
problems known to
Top Management - 4
Middle Managers - 9
Problems hidden from management
Supervisors - 74
Front-Line Employees - 100
Adapted from Sydney Yoshida, Japanese quality
HOW Create Momentum
  • Seek support for creating a culture of safety in
    the organization
  • Use your internal medical error and malpractice
  • Demonstrate how communication and teamwork can
    prevent many of these errors
  • Share successful stories from other facilities

  • Educate yourself
  • Understand the link between reliability science
    and patient safety culture
  • Become the go-to person for patient safety

HOW - Education
  • Provide safety science education
  • Frontline staff
  • Management/executives
  • Physicians
  • Provide teamwork training
  • ER teams
  • OR Teams
  • Provide education on communication techniques
  • All staff and physicians
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