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 Experience

Krishnan Sankaranarayanan MS, MBA, CPHQSenior Safety Officer- Tawam HospitalPresented at the NPSF Patient Safety Congress8-10 May 2013 New Orleans USA

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15th AnnualPatient Safety Congress

04/11/2023 2

Disclosure

The presenter has nothing to disclose, nor has any commercial interest with any of those information's displayed in this presentation.

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About Tawam Hospital• Tawam is a 466-bed tertiary care facility located in the garden city Al Ain in the

middle of the desert, and one among the largest healthcare facilities in the United Arab Emirates.

• In 2006 the General Authority of Heath Services now called as the Abu Dhabi Health Services Company PJSC (SEHA) entered in to a ten year affiliation contract with 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; Program

Accreditation)

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Items for discussion

• Ice breaker- Eric Cropp a pharmacist, the error that sent him to prison (Video)

• Second Victim• Comprehensive Unit-based Patient Safety program• Understanding the Culture of Safety journey from a

Middle East perceptive• Understanding how the concepts of leadership

engagement and learning from defects translated in to the organization

• Celebrating Safety- The Best Catch Award

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Ice Breaker

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Aftermath of an error- Shame & Blame

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Common Response After An Error

The 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 prematurely

when 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 Jan 2009).

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 J Qual Patient Saf 2007;33:467–76.

http://healthcare.monster.ca/8099_en-CA_pf.asp

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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

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Middle East: There no or lack of statistical evidence in this region to showcase patient deaths happening due to medical error

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This is what we see?

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The patients saw an average of 17.8 health professionals during their hospitalization

How many health professionals does a patient see during an average hospitalstay? N Whitt, R Harvey, S Child

The patients saw an average of 17.8 health professionals during their hospitalization

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Building a Culture of Safety

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Safety Culture comes from High Reliability Organizations

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Definition- Culture of Safety

• 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.

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Characteristics 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

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February 22, 2001, eighteen-month old Josie King died from medical errors at the Johns Hopkins Hospital

Peter J. Pronovost, MD, PhD is a practicing anesthesiologist and

critical care physician, teacher, researcher, and

international patient safety leader.

Johns Hopkins Medicine Comprehensive Unit-based Safety

Program-(CUSP)

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Comprehensive 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 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 defects b) Improving teamwork and communication

Step 6 : Resurvey staff about Safety Culture (annually)

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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

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Challenges faced at Tawam

• Employees hail from 60 different 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 of, “you made a mistake, and

you’re terminated.”

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CUSP -Pilot TestExecutive Leaders Adopted Units

• These units were selected partly due to their high risk & 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.

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CUSP is a leadership driven &

Partnership driven program

http://www.google.ae/imgres?imgurl=http://vik.podbean.com/wp-content/blogs/3111/uploads/open-to-partnership.jpg&imgrefurl=http://vik.podbean.com/category/communications/&usg=__A9p18KGBnSQliGu9VFIREzmAcWo=&h=516&w=800&sz=118&hl=en&start=17&zoom=1&itbs=1&tbnid=JRtZxgDsryzSHM:&tbnh=92&tbnw=143&prev=/images?q=partnership&hl=en&gbv=2&tbs=isch:1&ei=nek2Tc7nNoeyuAO4pI2yAw

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Stakeholders & Team

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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

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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.

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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)

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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

ICU

Pediatric Oncology

NNU

Domain

Av

era

ge

% P

os

itiv

e

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2 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.

Communication &

Team

work

Staffing

Medica

tion Erro

rs

Infection Contro

l

Policies

& Proced

ures

Educati

on

Equipmen

t

Others0%

5%

10%

15%

20%

25%

30%

2-item Staff Safety Survey

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

Areas of concern

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

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SAQ- Resurvey of CUSP pilot units

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2011 SAQ Phase-3 (Out-patient Units)

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2011 SAQ Phase-3 primary dependent variables

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SAQ- Action Plan

• De-briefer tool- least positive and most positive scores.

• Unit staff identified specific areas of concern and developed action plans for improvement.

• Rolled out CUSP in more units.

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CUSP Expansion Leadership Assigned to Twelve CUSP units

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Peds Oncology - CUSP Meeting Peds Oncology - CUSP Meeting

NICU- CUSP Meeting ICU- CUSP Meeting

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CUSP Executive walk rounds

Steve Talking to the House Keeping staff

COO ICU CUSP Executive Walk rounds CFO Peds Oncology - CUSP Executive Walk rounds

CEO NNU- CUSP Executive Walk rounds

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Executive walk rounds- Challenges

• Leaders asked frontline staff their safety concerns

• Instead of bringing up safety issues, staff typically talked about the protocols they followed to prevent harm.

• Nowadays they ask pointed question:- For instance

• “Have you had any problems with pharmacy recently on medications prepared for the ICU?”

• How is your communication with the Physicians??

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Culture linkages to Clinical, Operational & other Outcomes

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• 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

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ICU -VAP CLABSI & CAUTI

2006 2007 2008 2009 2010 2011 201202468

101214161820

17.3

5.5

2.34.2

5.3

2 1.8

Ventilator Associated Pneumonia -ICU

Ventilator Associated Pneumonia -ICU

Infe

ction

s/10

00 d

evice

day

s

2010 2011 20120

0.10.20.30.40.50.60.70.80.9

0.5

0.70.8

Central Line Associated Blood Stream Infec-tions - ICU

Rate/1000 device days

Infe

ction

s/ 1

000

devi

ce d

ays

2011 201288

89

90

91

92

93

94

95

96

97

91

96

ICU Average Rate for VAP Bundle Compliance

2011 201282

84

86

88

90

92

94

86

93

ICU Average Rate for CVL Bundle Compliance

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2009 2010 20110

0.2

0.4

0.6

0.8

1

1.2

0

1

0.3

Ventilator Associated Pneumonia -NICU

year

Infe

ction

s/10

00 d

evice

day

s

2009 2010 20110

1

2

3

4

5

6

76 5.9

3.6

Central Line Associated Blood Stream Infec-tions -NICU

year

Infe

ction

s/10

00 d

evice

day

s

NICU -VAP & CLABSI

44


2010 2011 20120

0.5

1

1.5

2

2.5

3

3.5

4

4.5

2.04

1.55

4.07

Central Line Associated Blood Stream Infections - Peds Oncology

year

CABS

I/10

00 d

evice

day

s

Peds Oncology- CLABSI

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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.

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ICU CLABSI Free Days

CUSP Team with the ICU Executive - COO

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NNU CLABSI Free Days

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“I Watch The Line”- Campaign

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

ICU NNU PICU

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Error Prevention“Learning from Defects”

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

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Formula 1 Pit stop

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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.

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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

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Learning from Defects- Tawam

Created 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.

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System changes due to PSN’s on Narcotic medication error

Verbal order carried out against policy for Narcotic medication. (Fentanyl Patch)Analyzed usage of each Narcotic and Controlled medication (for

the 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.

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Team members involved being felicitated

In the picture:Iyad Mahmoud; Jainy Mathew; Lynn Petrie; Krish and Dr. Said Abuhasna

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System changes due to PSN’s on Pressure Ulcers

9 PU’s reported between Oct 2011 &Mar 2012Joint investigation conducted Wound care nurse and wound care

link 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.

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Team members involved being felicitated -Wound care & RT

In the picture:Priya Padmanabhan; Stephanie Woodworth; Lynn Petrie; Krish and Dr. Said Abuhasna

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When errors occur one of the three things happen

• It can cause people to become championsOr • It can cause people to leave the profession

prematurely Or• It can make people go in to a shell and completely

feel withdrawn- Disengaged.

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Medication Error Story-1(Peds Oncology CUSP)

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

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Medication Error Story-2 (Peds Oncology CUSP)

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

6004/11/2023

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Medication Error Story-3 (Day Surgery CUSP)

What Happened

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

• Premedication of antihistamine, paracetamol 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

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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 have now become advocates of

patient safety by sharing their experiences.

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Distribution of Harmful Events by Care Units, 2010

Medical 1

Naima Pharmacy

OR

Paeds Medical

Medical 2

Paeds Oncology

0 20 40 60 80 100 120 140 160 180 200

113

128

139

152

163

183

13

0

29

10

11

3

No. Harmful eventNo. of Reported Event

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Medication 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 a clear case of the nurse not adhering to the principles of five rights and independently double checking the high alert medication. A case of negligence!!! The nurse had no previous history of such an error, was emotionally so distressed that the nurse could no more work in the unit. The patient family members did realize that the error was not intentional and did support the nurse who was devastated due to the incident. Despite the fact that CUSP was existence in that unit for over four years, there was no established mechanism to console the nurse. Due to the increased anxiety about the future possibility of errors and loss of confidence in ones own work, tragically the nurse chose to leave the specialty prematurely, the one that the nurse had been working for over fifteen years.

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Impact of CUSP on the staff

CUSP can turn ordinary people in to CHAMPIONS

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Best Catch Award program

Celebrating Safety – Viewing workers as heroes• Instituted in 2009 for the best near miss caught. • Now in the fifth 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.

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Best Catch Award 2010Peds Oncology CUSP

Abdulla Odat RN

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

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Best Catch Award 2011ICU CUSP

Rhian EvansAssociate Nurse Manager - ICU

Tawam Hospital

Synopsis :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

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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

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Up coming book called “Patients Come Second” by Paul Spiegelman & Britt Berrett

The book talks about caring for those (employees), who care for the patients. Employee engagement, getting them excited about providing good service to patients, which reflects on patient loyalty and good outcomes.

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Discussion-The End Game

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Healthcare Needs Robust System

• A cooperative effort between government agencies (regulatory authorities), Health Policy makers and industry to lead improvements in safety.

• Healthcare needs an independent body modeled after the National Transportation and Safety Board (NTSB).

National Medical Safety Board (NMSBSM) http://psoservices.net/nmsb/

http://psoservices.net/nmsb/

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Positive things happening in the Middle East region

United Arab Emirates-SEHA one of the largest healthcare systems in the region has

established 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 DATIX

Saudi Arabia- Is now asking all hospitals, government or private, to use online reporting for any serious medical error. Qatar- HMC has introduced real time incident reporting system at its chain of hospitals.

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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.

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Resources-websiteshttp://www.iom.edu/ http://www.npsf.org/ http://www.ihi.org/explore/patientsafety/pages/default.aspx http://www.hopkinsmedicine.org/armstrong_institute/ http://www.josieking.org/ https://www.patientsafetygroup.org/main/index.cfm http://www.pso.ahrq.gov/ http://www.patientsafety.gov/ http://www.safetyleaders.org/

http://www.iom.edu/

http://www.npsf.org/

http://www.ihi.org/explore/patientsafety/pages/default.aspx

http://www.hopkinsmedicine.org/armstrong_institute/

http://www.josieking.org/

https://www.patientsafetygroup.org/main/index.cfm

http://www.pso.ahrq.gov/

http://www.patientsafety.gov/

http://www.safetyleaders.org/

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References• 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, S Child• 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.• Pronovost PJ, Holzmueller CG, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual and Saf

2006 32(2):102-8.• Ginsburg, L., P. G. Norton, A. Casebeer, and S. Lewis. 2005. ‘‘An Educational Intervention to Enhance Nurse

Leaders’ 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 Saf 2010;36(6):252-260.

• 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 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, S Child• Ginsburg, L., P. G. Norton, A. Casebeer, and S. Lewis. 2005. ‘‘An Educational Intervention to Enhance Nurse

Leaders’ Perceptions of Patient Safety Culture.’’ Health Services Research 40 (4): 997–1020.

http://healthcare.monster.ca/8099_en-CA_pf.asp

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Thank YouPatient Safety Top Priority

Patient Safety Everyone's Responsibility

Contacts:[email protected]

+971 -50-9211649

mailto:[email protected]

Health & Medicine

A paradigm shift from blame to fair and just culture –a middle east hospital experience