A paradigm shift from blame to fair and just culture –a middle east hospital experience
“A Paradigm Shift From Blame To Fair And Just Culture”A Middle East Hospital ExperienceKrishnan Sankaranarayanan MS, MBA, CPHQSenior Safety Officer- Tawam HospitalPresented at the NPSF Patient Safety Congress8-10 May 2013 New Orleans USA
215th AnnualPatient Safety CongressDisclosureThe presenter has nothing to disclose, nor has anycommercial interest with any of those informationsdisplayed in this presentation.
315th AnnualPatient Safety CongressAbout Tawam Hospital• Tawam is a 466-bed tertiary care facility located in the garden city Al Ain in themiddle of the desert, and one among the largest healthcare facilities in the UnitedArab Emirates.• In 2006 the General Authority of Heath Services now called as the Abu DhabiHealth Services Company PJSC (SEHA) entered in to a ten year affiliation contractwith Johns Hopkins Medicine.• Tawam Hospital has current status with• Joint Commission International Accreditation (2006; 2009; 2012),• College of American Pathology (CAP; 2011) and• American College of Graduate Medical Education- International (ACGME; ProgramAccreditation)
415th AnnualPatient Safety CongressItems for discussion• Ice breaker- Eric Cropp a pharmacist, the error thatsent him to prison (Video)• Second Victim• Comprehensive Unit-based Patient Safety program• Understanding the Culture of Safety journey from aMiddle East perceptive• Understanding how the concepts of leadershipengagement and learning from defects translatedin to the organization• Celebrating Safety- The Best Catch Award
615th AnnualPatient Safety CongressAftermath of an error- Shame & Blame
715th AnnualPatient Safety CongressCommon Response After An ErrorThe types of suffering are• Increased anxiety about the future possibility of errors,• Loss of confidence in the work they do,• Some face difficulty sleeping,• Concern about their reputation as a care giver• Reduction in their sense of job satisfaction.• Excellent clinicians may leave the profession prematurelywhen involved in a preventable error.Rossheim J. To err is human—even for medical workers. Healthcare monster. http://healthcare.monster.ca/8099_en-CA_pf.asp (accessed 21 Jan2009).Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm JQual Patient Saf 2007;33:467–76.
815th AnnualPatient Safety CongressMedical error: the second victim..The term second victim was initially coined by Wu in hisdescription of the impact of errors on professionals. The doctorwho makes the mistake needs help too.In the aftermath of a mistake, its important the doctor seeksupport to deal with the consequences.Albert W Wu associate professorSchool of Hygiene and Public Health and School of Medicine, JohnsHopkins University, Baltimore, MD
915th AnnualPatient Safety CongressMiddle East: There no or lack of statistical evidence in thisregion to showcase patient deaths happening due to medicalerror
1015th AnnualPatient Safety CongressThis is what we see?
1415th AnnualPatient Safety CongressThe patients saw an average of 17.8 healthprofessionals during their hospitalizationHow many health professionals does a patient see during an average hospitalstay? N Whitt, R Harvey, S ChildThe patients saw an average of 17.8 healthprofessionals during their hospitalization
1515th AnnualPatient Safety CongressBuilding a Culture of Safety
1615th AnnualPatient Safety CongressSafety Culture comes fromHigh Reliability Organizations
1715th AnnualPatient Safety CongressDefinition- Culture of Safety• Safety culture is the ways in which safety is managed in theworkplace, and often reflects "the attitudes, beliefs, perceptionsand values that employees share in relation to safety" (Cox andCox, 1991).• The safety culture of an organization is the product of individualand group values, attitudes, perceptions, competencies, andpatterns of behavior that determine the commitment to, and thestyle and proficiency of, an organizations health and safetymanagement. Organizations with a positive safety culture arecharacterized by communications founded on mutual trust, byshared perceptions of the importance of safety, and by confidencein the efficacy of preventive measures. (AHRQ)Source: Organising for Safety: Third Report of the ACSNI (Advisory Committee on the Safety of NuclearInstallations) Study Group on Human Factors. Health and Safety Commission (of Great Britain).Sudbury, England: HSE Books, 1993.
1815th AnnualPatient Safety CongressCharacteristics of 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
1915th AnnualPatient Safety CongressFebruary22, 2001, eighteen-monthold Josie King died frommedical errors at theJohns Hopkins HospitalPeter J. Pronovost, MD, PhDis a practicing anesthesiologist andcritical care physician,teacher, researcher, andinternational patient safety leader.Johns Hopkins MedicineComprehensive Unit-based Safety Program-(CUSP)
2015th AnnualPatient Safety CongressComprehensive Unit-based Safety Program (CUSP)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 beharmed?▪ Please describe what you think can be done to prevent or minimize this harm?Step 4: Executive Walk RoundsStep 5:a) Learning from defectsb) Improving teamwork and communicationStep 6 : Resurvey staff about Safety Culture (annually)
2115th AnnualPatient Safety CongressHow we started at Tawam?• January-08 Created the Patient Safety dept.recruited 4 patient safety officers and a medicationsafety officer.• February-08 Leadership training on Patient Safety• April-08 Comprehensive Unit based Safety ProgramRoll-Out.• 2008- ICU, NNU, Peds Onc (Pilot Units)• 2011- Medical 1 & 2, Surgical 1& 2, Daycase, PICU• 2012- OBGYN• 2013- OR & ED
2215th AnnualPatient Safety CongressChallenges faced at Tawam• Employees hail from 60 different nations• Hierarchies between providers• A culture that isn’t accustomed to acknowledgingmedical errors.• Tendency for poor communication and teamworkthat lead to adverse events.• Tawam had a history of, “you made a mistake, andyou’re terminated.”
2315th AnnualPatient Safety CongressCUSP -Pilot TestExecutive Leaders Adopted Units• These units were selected partly due to their highrisk & high volume nature and closed medical staff.The units were selected in part due to;-their high-risk, high-volume nature and use of closed medical staffs.
2415th AnnualPatient Safety CongressCUSP is a leadership driven &Partnership driven program
2515th AnnualPatient Safety CongressStakeholders & Team
2615th AnnualPatient Safety CongressBaseline assessment-Safety Attitudes QuestionnaireCulture of Safety Survey- Domains1.Teamwork Climate2.Safety Climate3.Job Satisfaction4.Stress Recognition5.Working Conditions6.Perceptions of Hospital Management7.Perceptions of Unit Management
2715th AnnualPatient Safety CongressDependent Variables of SAQ• The primary dependent variables -teamworkclimate and safety climate scale scores.• These primary dependent variables were chosenbecause they are important in preventing patientharm.• The rest of them are secondary dependentvariables.Sexton J.B., et al.: The Safety Attitudes Questionnaire: Psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res6(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 safetyculture in a surgical inpatient unit. Jt Comm J Qual Patient Saf 2010;36(6):252-260.
2815th AnnualPatient Safety CongressLocation YearTargetedstaffSurveysAdministeredSurveyReturnedSurveyresponseratePhase 1 CUSP Pilot Units 2008 199 199 199 100%Phase 2 In-patient areas 2010 1600 1476 1450 98%Phase 3Out-Patient & satellitelocationsQtr 42011 805 497 483 60%Total 2604 2172 213282% 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)
3015th AnnualPatient Safety Congress2 question survey: Pilot Units- 2008Please 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.0%5%10%15%20%25%30%Communication& TeamworkStaffing MedicationErrorsInfection Control Policies &ProceduresEducation Equipment OthersAreas of concern2-item Staff Safety SurveyICU N=93NICU N=73Peds Onc N=39
3115th AnnualPatient Safety Congress2010 SAQ Phase-2(All In-patient Units- & CUSP Pilot Units Re-survey)
3615th AnnualPatient Safety CongressSAQ- Action Plan• De-briefer tool- least positive and most positivescores.• Unit staff identified specific areas of concern anddeveloped action plans for improvement.• Rolled out CUSP in more units.
3715th AnnualPatient Safety CongressCUSP ExpansionLeadership Assigned to Twelve CUSP units
3915th AnnualPatient Safety CongressCUSP Executive walk roundsSteve Talking to the House Keeping staffCOO ICU CUSP Executive Walk rounds CFO Peds Oncology - CUSP Executive Walk roundsCEO NNU- CUSP Executive Walk rounds
4015th AnnualPatient Safety CongressExecutive walk rounds- Challenges• Leaders asked frontline staff their safetyconcerns• Instead of bringing up safety issues, stafftypically talked about the protocols theyfollowed to prevent harm.• Nowadays they ask pointed question:- Forinstance• “Have you had any problems with pharmacy recently onmedications prepared for the ICU?”• How is your communication with the Physicians??
4515th AnnualPatient Safety CongressCLABSI Free DaysICU• 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.
4615th AnnualPatient Safety CongressICU CLABSI Free DaysCUSP Team with the ICU Executive - COO
4715th AnnualPatient Safety CongressNNU CLABSI Free Days
4815th AnnualPatient Safety Congress“I Watch The Line”- Campaign• To increase staff awareness• To ensure staff active involvement• To ensure conscientious implementationICU NNU PICU
4915th AnnualPatient Safety CongressError Prevention“Learning from Defects”“Smart people learn from theirown mistakes, wise people learnfrom others mistakes.”
5115th AnnualPatient Safety CongressFormula 1 Pit stop• Takes six to twelve seconds in duration.• Every pit stop is filmed and monitored byhuman factor experts• Errors are scored in five levels• Highest score goes to the smallesterror, because people are unaware of it.
5215th AnnualPatient Safety CongressAviation-Sterile cockpit rule• Prohibits crew member performance of non-essential duties or activities while the aircraft isinvolved in taxi, takeoff, landing, and all other flightoperations conducted below 10,000 feet, exceptcruise flight.• Prohibits the personal use of a personal wirelesscommunications device or laptop computer while aflight crew member is at duty station during allground operations
5315th AnnualPatient Safety CongressLearning from Defects- TawamCreated Safety Event Analysis Teams ineach CUSP unit.Identified a team of believersTeam identified defects from Patient Safety Net(PSN)Implemented systems changes to reduce theprobability of recurring.At least one defect was investigated eachmonth.
5415th AnnualPatient Safety CongressSystem changes due to PSN’s on Narcoticmedication errorVerbal order carried out against policy for Narcoticmedication. (Fentanyl Patch)Analyzed usage of each Narcotic and Controlled medication (forthe previous six months).Determined Critical/emergency need of each n drug.List of Narcotic and Controlled medications were reduced to half.ICU physicians and nurses informed about the changes.Review the usage every 3 months.
5515th AnnualPatient Safety CongressTeam members involved being felicitatedIn the picture:Iyad Mahmoud; Jainy Mathew; Lynn Petrie; Krish and Dr. Said Abuhasna
5615th AnnualPatient Safety CongressSystem changes due to PSN’s on Pressure Ulcers9 PU’s reported between Oct 2011 &Mar 2012Joint investigation conducted Wound care nurse and wound carelink nurse.Developed Nursing care plan.Conducted 0ne to one education.Involved Respiratory Therapists.BIPAP gel masks will be used to prevent PU’s related to BIPAP.
5715th AnnualPatient Safety CongressTeam members involved being felicitated -Wound care & RTIn the picture:Priya Padmanabhan; Stephanie Woodworth; Lynn Petrie; Krish and Dr. Said Abuhasna
5815th AnnualPatient Safety CongressWhen errors occur one of the three things happen• It can cause people to become championsOr• It can cause people to leave the professionprematurelyOr• It can make people go in to a shell and completelyfeel withdrawn- Disengaged.
5915th AnnualPatient Safety CongressMedication Error Story-1(Peds Oncology CUSP)Double check forexpiration date notdone properlyFirst Nurse proceededto administer thevaccine without takingthe tablet PC to thepatient bed sideVaccine Injected andasked second Nurse tochart in Cerner on hisbehalfSecond Nurse baffled after seeingthe expiration date and themissing expiration date in thelabelError reachedthe patient butdid not causeharmExpired vaccinearrived fromPharmacySWISS CHEESE MODEL
6015th AnnualPatient Safety CongressMedication Error Story-2 (Peds Oncology CUSP)ChemotherapyWritten by MD.VincristinedoxorubicinAndl_aspargenesCheckedaccordingTo the protocolThen faxedto pharmacyPrepared byPharmacyMedicationReceived fromPharmacy,Checked withAnotherChemotherapyCompetentNurseVCRDOXOL-AspTwo medicationtaken topatient roomVCRandDOXOAndEmla creamL-Asp returned tofridge602013-4-29
6115th AnnualPatient Safety CongressMedication Error Story-3 (Day Surgery CUSP)WhatHappened• Remicade a non formulary was administered to the patient (order wasin paper)• Premedication of antihistamine, paracetamol was ordered in CERNERwhich was not communicated to the nurse• The patient developed allergic reactionsWhat Next• Investigation revealed that there was no set protocols or guidelines• Break down in communication & information transferAction• Guidelines, protocols and checklist were developed• No incidents since then
6215th AnnualPatient Safety CongressImplication of the errors• The staff came open and reported the incidents• Since CUSP was in place it helped institute a Fairand Just Culture• Investigation of the incidents, examined theprocesses and not just people.• The three nurses have now become advocates ofpatient safety by sharing their experiences.
6315th AnnualPatient Safety CongressDistribution of Harmful Events by Care Units, 20100 20 40 60 80 100 120 140 160 180 200Medical 1Naima PharmacyORPaeds MedicalMedical 2Paeds Oncology1131281391521631831302910113No. Harmful eventNo. of Reported Event
6415th AnnualPatient Safety CongressMedication Error Story-4-(Second Victim)A nurse inadvertently administered a chemotherapy drug to a wrong patient.The patient was ok and the error was openly disclosed to the family. It was aclear case of the nurse not adhering to the principles of five rights andindependently double checking the high alert medication. A case ofnegligence!!!The nurse had no previous history of such an error, was emotionally sodistressed that the nurse could no more work in the unit. The patient familymembers did realize that the error was not intentional and did support thenurse who was devastated due to the incident.Despite the fact that CUSP was existence in that unit for over fouryears, there was no established mechanism to console the nurse. Due to theincreased anxiety about the future possibility of errors and loss of confidencein ones own work, tragically the nurse chose to leave the specialtyprematurely, the one that the nurse had been working for over fifteen years.
6515th AnnualPatient Safety CongressImpact of CUSP on the staffCUSP can turn ordinary people in toCHAMPIONS
6615th AnnualPatient Safety CongressBest Catch Award programCelebrating Safety – Viewing workers asheroes• Instituted in 2009 for the best near miss caught.• Now in the fifth year of implementation.• Provided opportunity for staff to proactivelyidentify and implement risk reduction strategies.• 2010, 2011 & 2012 Best Catch awards went toCUSP units.
6715th AnnualPatient Safety CongressBest Catch Award 2010Peds Oncology CUSPSynopsis :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 ofChemotherapy medication
6815th AnnualPatient Safety CongressBest Catch Award 2011ICU CUSPRhian EvansAssociate Nurse Manager - ICUTawam HospitalSynopsis :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 andaccidental fire in the ICU
6915th AnnualPatient Safety CongressBest Catch Award 2012Peds Oncology CUSPSynopsisThe physician had ordered Metototrexate IT for this patient. In OR the mother of thepatient told the nurse that the patient should receive Cytarabin IT, not Metotrexate. ThePhysician had prescribed the wrong drug.Prevented administration of wrongchemotherapy medication
7015th AnnualPatient Safety CongressUp coming book called “Patients Come Second” by PaulSpiegelman & Britt BerrettThe book talks about caring for those (employees), who care forthe patients. Employee engagement, getting them excited aboutproviding good service to patients, which reflects on patientloyalty and good outcomes.
7115th AnnualPatient Safety CongressDiscussion-The End Game
7215th AnnualPatient Safety CongressHealthcare Needs Robust System• A cooperative effort between government agencies(regulatory authorities), Health Policy makers andindustry to lead improvements in safety.• Healthcare needs an independent body modeled afterthe National Transportation and Safety Board (NTSB).National Medical Safety Board (NMSBSM)http://psoservices.net/nmsb/
7315th AnnualPatient Safety CongressPositive things happening in the Middle East regionUnited Arab Emirates-SEHA one of the largest healthcare systems in the region hasestablished the PSN reporting tool in all its business entities.DHA Implements New Patient Safety System called “Aman”based on a global healthcare safety system called DATIXSaudi Arabia- Is now asking all hospitals, governmentor private, to use online reporting for any seriousmedical error.Qatar- HMC has introduced real time incident reportingsystem at its chain of hospitals.
7415th AnnualPatient Safety CongressCulture of Safety is a journey• It takes as long as 5 years to develop aculture of safety that is felt throughoutan organization. (Ginsburg et.al 2005)• NeedPatience, Perseverance, Commitment &Engagement.
7615th AnnualPatient Safety CongressReferences• Kohn LT, Corrigan JM, Donaldson MS, editors. To Err Is Human: Building a Safer Health System.Washington: National Academy Press; 1999• How many health professionals does a patient see during an average hospital stay? N Whitt, R Harvey, SChild• Sexton J.B., et al.: The Safety Attitudes Questionnaire: Psychometric properties, benchmarking data, andemerging research. BMC Health Serv Res 6(44):Apr. 3, 2006.• Pronovost PJ, Holzmueller CG, et al. A practical tool to learn from defects in patient care. Jt Comm J Qualand Saf 2006 32(2):102-8.• Ginsburg, L., P. G. Norton, A. Casebeer, and S. Lewis. 2005. ‘‘An Educational Intervention to Enhance NurseLeaders’ Perceptions of Patient Safety Culture.’’ Health Services Research 40 (4): 997–1020.• 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 Saf2010;36(6):252-260.• Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians inthe United States and Canada. Jt Comm J Qual Patient Saf 2007;33:467–76• Rossheim J. To err is human—even for medical workers. Healthcare monster.http://healthcare.monster.ca/8099_en-CA_pf.asp (accessed 21 Jan 2009).• Wu AW (2000). "Medical error: the second victim. The doctor who makes the mistake needs help too".BMJ 320 (7237): 726–7.• How many health professionals does a patient see during an average hospital stay? N Whitt, R Harvey, SChild• Ginsburg, L., P. G. Norton, A. Casebeer, and S. Lewis. 2005. ‘‘An Educational Intervention to Enhance NurseLeaders’ Perceptions of Patient Safety Culture.’’ Health Services Research 40 (4): 997–1020.