1. 30
MARCH/APRIL2013
Just as Rome was not built in a day, the culture of
any one health care provider doesn’t spring up
overnight. Over time, several forces—from per­
sonal attitudes to management style—shape a
unique set of mores that affect behavior. Yet, when
it comes to safety, behavior is the primary difference
maker. Different actions can bring about radically
diverse outcomes.
While there is much to learn about promoting patient
and workplace safety, health care in general has done a
poor job of implementing what it already knows. This
was made astonishingly clear in the Institute of
Medicine’s (IOM) groundbreaking report, “To Err is
Human,” as well as in multiple subsequent research
studies. IOM first pegged the price of preventable med­
ical errors at 44,000 to 98,000 lives per year and $17 to
$29 billion per year.1
A few years later, the U.S. Centers
for Disease Control and Prevention (CDC) made us fear
we’d only seen the tip of the iceberg when it reported
that health care­associated infections (HAI) alone were
responsible for the deaths of nearly 99,000 patients per
year.2
Regardless, the data reveal a tremendous gap
Weaving Safety into Everyday Practice
How One Provider is Building a Culture of Safety in its Practice
By Jeannie Counce

2. MARCH/APRIL2013
31
between known best practice and the ability to actually
deliver that care to patients.
Culture Clash No More
To get a handle on how safety can be improved in
health care, researchers studied high­reliability organi­
zations, which are considered to operate with nearly
failure­free performance. The most commonly cited
examples are air traffic control systems, nuclear power
plants, and naval aircraft carriers—which, like health
care, are high­risk, high­consequence endeavors.
Detailed case studies identified common features asso­
ciated with substantial improvements in their safety
records; chief among them is a culture of safety.3
What is a culture of safety? Definitions abound, but
essentially a culture of safety involves commitment
and participation at all levels. Organizations with
advanced safety cultures develop ways to detect
unexpected threats and contain them before they
cause harm—or bounce back when they fail. They are
attentive to issues facing workers on the frontline and
involve them in root cause analysis of safety breaches
as well as in organizational decision­making. And, all
individuals have a sense of autonomy to act when a sit­
uation does not “feel right” and are encouraged to
report potential hazards and errors as part of an ongo­
ing improvement process.3
In many ways culture is the key to reducing medical
errors and complications—which can, in turn, pre­
vent injury, death, and unnecessary costs to the
health care system. Providers know that simple
steps like hand washing prevent the spread of infec­
tion and reduce complications. Yet, research has
shown that health care providers adhere to national
guidelines for hand hygiene less than 50% of the
time.4
In a culture of safety, the workplace embraces
operational change—like the issuing of hand washing
guidelines—effectively and consistently incorporat­
ing it into everyday practice.
Bringing the Culture to the
Alternate-Site
There’s an abundance of research on patient safety ini­
tiatives, but as is typically the case, the majority of them
are in the acute care setting. As part of an academic,
integrated health system, Baltimore­based Johns
Hopkins Home Care Group (JHHCG) provides an excel­
lent case study that relates directly to the alternate­site
infusion field. Working with Johns Hopkins Medicine, a
pioneer in patient safety research and innovation,
JHCCG has a unique perspective on the benefits of safe­
ty and quality to both patients and workers, as well as a
decade of experience cultivating a culture of safety (see
box for history).
“Safety is interwoven in everyday practice, not lay­
ered on top,” says Mary Myers, Vice President and
COO of JHHCG. While this may be a foundational prin­
ciple in a culture of safety, it doesn’t happen
overnight, she adds. “Eight to 10 years ago we were at
the infant stage. We have come a long way, but we’re
still growing.”
Getting there is a continuous process that requires
several ingredients (see Exhibit 1). “Trust and trans­
parency are vital,” observes Myers. “Our team has to
know that it’s okay to report issues without being afraid
that they will ‘get in trouble.’”
Establishing this type of trust is a culture change,
points out Linda Beckett, Infusion Production
Technician. While Beckett and most of her teammates
feel comfortable self reporting, newer employees are
more hesitant at first. “We had a pharmacy employee
catch an error when a prescription came back for refill,”
recalls Beckett. The employee couldn’t believe how our
process worked compared to their former employer,
History of Safety at Johns
Hopkins
In 2002, following two tragic and highly publicized
lapses in patient safety, Johns Hopkins Medicine set a
goal of making its care the safest in the world.
Central to that effort was the creation of a Center for
Innovation in Quality Patient Care to spur advances in
quality and patient safety. Through research and col­
laboration, the center developed a set of customiz­
able tools and resources to help frontline clinicians
identify and mitigate hazards to quality patient care.
The most widely publicized example is the
Comprehensive Unit­Based Safety Program (CUSP),
which emphasizes a systematic, team­based
approach to quality improvement work. By imple­
menting this model along with other evidence­based
interventions, Hopkins was able to reduce its rate of
central line–associated bloodstream infections
(CLABSIs) in surgical intensive care units by 75­100%
from 2001 to 2010.5
Other units employing CUSP also
have experienced improved staff morale and lower
nursing turnover. The model has been disseminated
to hospitals nationwide, and in intensive care units in
Michigan hospitals it was associated with a sustained
66% reduction in CLABSIs.6
The center later merged with the Quality and
Research Safety Group, led by Peter Pronovost, M.D.,
to become the Armstrong Institute for Patient Safety
and Quality. The Institute provides an infrastructure
that oversees, coordinates, and supports patient
safety and quality efforts across Johns Hopkins’ inte­
grated health care system and shares tools and
expertise with other health care providers.

3. 32
MARCH/APRIL2013
who would have fired them on the spot. Instead, the
employee was rewarded for coming forward and
became an integral part of the solution.”
Removing the penalties from self reporting builds
trust. It also encourages further reporting—another
key ingredient, according to Myers. “We want to
encourage reporting. Our team knows that if some­
thing doesn’t feel right, doesn’t sound right, doesn’t
look right, it probably isn’t right. We’re counting on
everyone to trust their instincts and speak up when
they suspect safety could be compromised,” she says.
This recently played out when Nancy England,
Infusion Clinical Technician, was reviewing a list of
patient supply needs. “I noticed that one patient was
requesting a lot more flushes than they should need to
administer their therapy,” she recalls. “It didn’t feel
right, so I checked with the patient, involved the phar­
macists and it turned out the patient’s physician was
supplying additional medication—the reason for the
extra flushes—that wasn’t compatible with the therapy
we were supplying.”
Errors, near misses, and practices that could con­
tribute to mistakes are all important springboards for
improvement. “We reward the identification of issues
because we can learn from them,” says Myers. “When
a mistake is made, part of the solution is performing a
Root Cause Analysis (RCA) and creating a risk reduction
strategy. Errors are most often system issues, not peo­
ple issues, so this model is effective.”
“Usually things we identify result in performance
improvement projects,” explains Beckett. In one exam­
ple, a review of the “pre­delivery error log” revealed
that two saline solutions with different volumes were
placed next to each other in the supply area. Their
proximity increased the chances of error in stocking
and/or use in compounding.
Having the Tools to Act
While reacting appropriately and learning from safety
issues is critical, JHHCG strives to be more than just
reactive when it comes safety, according to Myers.
“We conduct Failure Mode and Effects Analysis (FMEA)
and other activities that are proactive.”
In one example the team conducted a FEMA on infu­
sion pump programming. “We realized that there are
60 different steps involved—multiplied by the number
of hands touching the pumps,” recalls David Hirsch,
R.N., Nurse Manager for Adult Services. “We then cal­
culated the number of possible mistakes and severity of
each one and came up with a prioritized list of items for
improvement.” The list is implemented one step at a
time and the results are carefully measured.
“You can’t make a whole bunch of changes at once,
because you won’t know which was effective,” points
out Krista Decker, R.Ph., Medication Safety Officer.
“We use quality improvement (QI) tools like ‘Plan­Do­
Exhibit 1
Cultivating a Culture of
Safety
Necessary Ingredients
Trust
Transparency
Proactive
Non­punitive, “just culture” where employees aren’t
culpable for honest mistakes
Collaborative
Empowers autonomous action
Interdisciplinary in nature
Ability to learn from defects
Action Steps
Create a formal program
Demonstrate how safety supports the organization’s
mission
Consider safety of patient, employee, and environment
Provide tools and training
Involve patients and caregivers
Set expectations
Encourage team members to trust their instincts
Conduct safety rounds
Reward identification of issues (including self reporting)
Communicate adverse events
Conduct root cause analyses when mistakes are made
Identify trends
Close the loop whenever possible
Measure (attitudes toward safety, patient and
employee satisfaction, progress)
Use dashboards to monitor progress
Learn from others and share your knowledge
Remember that you can ALWAYS improve

4. MARCH/APRIL2013
33
Check­Act,’ (PDCA) and look at the data so we can see
what is improving and by how much.”
While QI theory factors heavily into their work, the
team acquires knowledge along the way. “Mary has
background in quality, which is a significant advan­
tage,” notes Mitra Gavgani, Pharm.D., Director of
Pharmaquip Infusion Services for JHHCG. “She
appreciates the tools and encourages all the staff—
not just managers—to take part in training and par­
ticipate in forums like our Quality Safety Council.”
The council, which is open to all employees, identifies
the issues that the team will address each year and
writes a plan on how to achieve its goals. Included in
the plan is an assessment of the various tools they’ll
need to get there, which in turn, determines the
training schedule.
“We send our team members to learning events and
tap into the resources at the Armstrong Institute,”
explains Myers. “We have adapted many of their hos­
pital initiatives to our mobile workforce.”
In addition to training, system improvements involve
arming staff with the basic tools to do the job, says Fred
Choy, R.Ph., Infusion Pharmacy Manager. “That means
access to the hospital computer to see patients’ electron­
ic medical records, the ability to research critical informa­
tion like drug data, and communicate in real time.” JHHCG
provides the tools its staff needs, including smart phones
with apps and programs like drug libraries for reference,
and the ability to text each other in real time.
Access to tools and resources is advantageous, but
not mandatory for success, points out Gavgani. “No
tools will help you if you are not willing to listen,” she
asserts. “It doesn’t take a lot of money to open your
ears and listen to what your staff has to offer—they are
your best consultant.”
Listening to the Consultants
In the 10 years that JHHCG has been working to improve
safety, it has adopted a number of practices based on
the wisdom of its team. The organization’s clinical
teams specialize by disease state, which allows them to
stay more focused and to be very knowledgeable about
the latest treatment protocols, according to Gavgani.
“For example, there is a pharmacist and a pharmacy
technician dedicated solely to pediatrics. Adults are
divided by the disease state,” she explains. “One team
is dedicated to oncology and pain patients, which pro­
vides important continuity for patients experiencing
extreme pain due to their treatment or in cases where
they transition to hospice.”
“We also have fre­
quent huddles
throughout the day to
address issues as they come
up,” says Beckett. “We had
one today about
chemotherapy
and priming
tubing, and
we’ve had
many over the
past year or so on
the drug shortages.”
The team has creat­
ed its own checklists
built on evidence­based
practices. “The checklists
help us maintain consistency
and minimize risk of error,”
observes Myers. “We have them for
pre­delivery, home administration of
drugs, dressing changes, line care and hand wash­
ing.”
They also conduct safety rounds, where teams walk
through their daily operations to see where they might
prevent injuries. “We are always asking, ‘How could we
hurt a patient? Where is the next error coming from?’”
explains Myers, who often performs her own executive
rounds, going on home visits with nurses and sitting
with customer service representatives in the phone
center to examine work practices and solicit feedback.
Similarly, there’s a Home Observation Program,
where a staff member, who is not involved in caring
for a specific patient, observes a patient visit in the
home and reviews the events with the clinician, com­
municating opportunities for improvement. The team
conducts frequent case reviews in staff meetings.
When patient care issues are identified, the review can
sometimes lead back inside the hospital system to the
department where the problem originated. The team
also works proactively with physicians when they see a
potential problem with an order—they’ll stop it and go
back to explain where the safety issue is and how it
could be improved.
“This culture goes across the system—everyone is col­
laborative and respectful,” interjects Susan Martin, Senior
Director of Contracting and Business Development. “Our
team offers a ‘home care 101’ session to physicians and
other referral sources on the system’s hospital side to
teach them what’s needed for safe discharge and show

5. 34
MARCH/APRIL2013
them what the home environment is like.”
That type of education pays off many times, accord­
ing to Martin. Since Hopkins is an academic medical
center, the physicians coming out of the system are
well versed in infusion and more open to collaborating
with their home care partners. “They often call to
access our clinicians’ expertise, like asking for recom­
mendations on PICC lines or to develop safe plans to
transition patients from the hospital to home infusion,”
she says.
JHHCG’s collaborative nature extends into the com­
munity as well. Gavgani says that the team will also edu­
cate physicians and referral sources outside the system
on potential errors coming from their practices. “They
usually start off thinking ‘Who are you to question me?’
but eventually they understand we are not pointing fin­
gers, we are working for the patient,” she observes.
Advocating for the patient—and turning would­be­
errors into near misses—has built relationships and
earned JHHCG loyalty from many of its referral sources.
“There was one infectious disease group that was not
very open to change at first,” recalls Gavgani, “but they
saw the benefits to the patients and the errors that
were avoided by our pharmacist and now they insist on
using us.”
Patient Involvement
Involving patients and caregivers is another key ingredi­
ent in a culture of safety. As with the employee culture,
trust is an essential element in patient care. “As field
clinicians we develop a relationship with the patient and
the family,” explains Hirsch. “We want to make them
feel confident and involved.” To do that, Hirsch and the
other clinicians review the medication order, show
them the medication and supplies, and perform a return
demonstration using teach­back technique.
“We involve the family in the Five R’s checklist,” he
continues, referring to the “right medication, right
dose, right patient, right time, right administration
route” axiom of medication delivery. “We also include
information on the ‘Speak Up’ campaign in their educa­
tion materials,” adds Hirsch. The campaign, part of a
Joint Commission effort to increase involvement in
patient care, produces brochures and materials on top­
ics such as avoiding medication errors, fighting infec­
tion, and controlling pain.
JHHCG believes that hand hygiene is the front line of
infection control, according to Myers. “We have adopted
the World Health Organization’s Five Moments technique,
which is more rigorous than what’s typically done in the
hospitals,” she says. “We are teaching this to patients and
caregivers as well so they can implement it in self­care, and
check our clinicians working in their home.”
The team also taps into the wisdom of patients by
including safety questions on their patient satisfaction
surveys. “We ask them to share their concerns regard­
ing safety and give us recommendations for improve­
ment,” says Myers.
Patients are invited to serve on advisory committees
and give input into various improvement projects as
well. “Four or five years ago we were looking at new
pumps and solicited opinions from patients,” recalls
Choy. “We had them test out a couple of options, and
went with their recommendation—the lower­tech
pump, which was less confusing to operate.”
Satisfaction all Around
Knowing that they are playing a part in positive changes
motivates employees to become active participants in
the safety culture. “You get encouragement and learn
to trust when you see the loop closed on an issue,”
obverses Beckett. “Even more important than the out­
come is knowing you’ve been heard.”
“We perceive happiness from finding the best way to
serve patients,” adds England. “We strive to treat them
like we would members of our own family and that
means protecting them from harm.”
Not only is this approach good for patients in terms of
improved outcomes, but it also increases patient satis­
faction—and employee satisfaction. “Employee satis­
faction, patient satisfaction, and culture of safety all
align,” observes Myers.
In fact, research, conducted by Bryan Sexton, a for­
mer faculty member at Johns Hopkins University
School of Medicine who created the Safety Attitudes

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Resources
Armstrong Institute for Patient Safety and Quality
http://www.hopkinsmedicine.org/armstrong_institute/
Agency for Healthcare Research and Quality
Safety Culture Primer
http://psnet.ahrq.gov/primer.aspx?primerID=5
Pharmacy Survey on Patient Safety
http://www.ahrq.gov/qual/pharmsurvey/pharmsopsform.pdf
Occupational Safety and Health Administration (OSHA)
Linking Patient and Worker Safety
http://www.osha.gov/SLTC/healthcarefacilities/safetycul­
ture_full.html
Joint Commission
Speak Up Initiatives
http://www.jointcommission.org/speakup.aspx
World Health Organization
Five Moments for Hand Hygiene
http://www.who.int/gpsc/tools/Five_moments/en/
Learn More
Members of the Johns Hopkins Home Care
Group team will be presenting on two qual­
ity­related topics at NHIA’s Annual
Conference & Exposition in Dallas. Be sure
to check out:
• Performance Improvement: Not Just a
“To Do”—But a Real Tool for Improving
Your Business (02­A). Monday, April 8,
1:30 to 3:00 PM
• A Leadership & Management Workshop
program titled “Leveraging Evidence­
Based Tools to Maximize Employee
Development and Impact,” which
includes two sessions:
— Creating an Engaged Workforce:
Indentifying Employee Needs (22­F).
Thursday, April 11, 9:00 to 10:30 AM
— Creating an Engaged Workforce:
Developing and Implementing an
Employee­Driven Action Plan (26­G).
April 11, 10:45 AM to 12:45 PM

7. Questionnaire used by the Center of Innovation,
indeed shows a positive correlation between a high
culture of safety score and improved patient out­
comes, including reduced length of stay, fewer med­
ication errors, and lower rates of complications, such
as ventilator­associated pneumonia and bloodstream
infections. But, Sexton also found a positive correla­
tion between a high culture of safety score and sever­
al human resources metrics, such as higher staff reten­
tion, higher employee morale, lower staff burnout,
and less absenteeism.7
This is not surprising, consider­
ing that a culture of safety requires good communica­
tion, teamwork, and management support, which also
play heavily into employee engagement.
Commitment to personal growth is another byprod­
uct of a safety culture, points out Gavgani, noting that
the just culture that encourages self­reporting is not an
excuse for sloppy work. “We set expectations with our
mission and vision, so there is accountability,” she
explains. “That level of dedication changes everyone,”
she says. “You are more likely to examine your weak­
nesses and improve your skills.”
JHHCG regularly gauges employee satisfaction,
patient satisfaction, and culture of safety through blind­
ed surveys. “The results give us a barometer of where
we are and show us areas for improvement,” Myers
explains. “We can always improve,” she adds. “There
will always be an error—how we handle it is what
makes the difference.”
Jeannie Counce is INFUSION’s Editor-in-Chief. She can be
reached at: jeannie.counce@nhia.org or 406-522-7222
References
1. Institute of Medicine. To err is human: Building a
safer health system. November 1999. National
Academy Press. Available at www.iom.edu/
~/media/Files/Report%20Files/1999/To­Err­is­
Human/To%20Err%20is%20Human%201999%20%20rep
ort%20brief.pdf (accessed 2/28/13).
2. Klevens RM, Edwards JR, Richards CL, et al.
Estimating health care­associated infections and
deaths in U.S. hospitals, 2002. Public Health Reports.
March­April 2007:160­166. Available at
www.cdc.gov/HAI/pdfs/hai/infections_deaths.pdf
(accessed 2/28/13).
3. Agency for Healthcare Research Quality (AHRQ).
Patient Safety Network Glossary: High reliability
organziations. Available at
http://psnet.ahrq.gov/popup_glossary.aspx?name=
highreliabilityorganizations (accessed 2/28/13)
4. D Pittet, P Mourouga, Perneger T. (1999)
For information on digital advertising or sponsorship, contact David Gershman at 703­838­2665 or David.Gershman@nhia.org
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Go to www.nhia.org/infusiononline to download your copy today!
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8. Compliance with hand washing in a teaching hospi­
tal. Annals of Internal Medicine 130(2), pp. 126–130.
5. Commonwealth Fund. Case Study: Keeping the com­
mitment: Progress in patient safety. March 2011.
Available at /www.commonwealthfund.org/~/
media/Files/Publications/Case%20Study/2011/Mar/147
4_McCarthy_Johns_Hopkins_case_study_COR­
RECTED_05292012.pdf (accessed 2/28/13).
6. P. Pronovost, D. Needham, S. Berenholtz et al., “An
Intervention to Decrease Catheter­Related
Bloodstream Infections in the ICU,” New England
Journal of Medicine, Dec. 28, 2006 355(26):2725–32.
7. Johns Hopkins Medicine, Center for Innovation in
Quality Patient Care. Why is safety culture impor­
tant? Available at www.hopkinsmedicine.org/inno­
vation_quality_patient_care/areas_expertise/impro
ve_patient_safety/culture/why_important.html
(accessed 2/28/13).
2014
NHIA Annual Conference & Exposition
Save the Date!
March 31 - April 3, 2014
Orlando, Florida
Tobeaddedtothe2014NHIAAnnualConference&Expositionattendeemailinglistortolearnabout
exhibit,sponsorship,and/oradvertisingopportunities,contactNHIAatinfo@nhia.orgor703­838­2663.