8/3/2015
49th Annual Meeting
Disclosure

Strategies to Improve Safety:
What Really Works
I do not have a vested interest in or affiliation with
any corporate organization offering financial
support or grant monies for this continuing education
activity, or any affiliation with an organization
whose philosophy could potentially bias my
presentation
Natasha Nicol, Pharm D, FASHP
Director, Global Patient Safety Affairs
Cardinal Health
OWNING CHANGE: Taking Charge of Your Profession
Objectives
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TMI time!
Discuss the strategies recognized in the literature for improving
patient safety
Describe how to conduct an effective root cause analysis
Define a just culture and how it is necessary in order to
improve safety
Discuss just culture implementation strategies
List the steps to take when conducting an event investigation in
order to understand how to prevent future errors
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I am a pharmacist; I was a technician for 9 years
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I love to travel
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I buy most of my (limited) wardrobe at consignment shops and drive my trucks
until they have 300,000 miles
I have made mistakes in my life
Hospital Survey on Patient Safety Culture
by AHRQ
(Agency for Healthcare Research and Quality)
“Medicine used to be simple, ineffective, and relatively
safe. Now it is complex, effective, and potentially
dangerous”
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Only 44% of employees are confident they wouldn’t
be punished if they reported an error
-Sir Cyril Chantler
https://www.flickr.com/photos/uclnews/8005869769/; accessed 6.22.15 10:31 am
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Emily Jerry – 2006, Ohio
17-year-old Jesica – 2003, Duke
http://www.dukechronicle.com/blogs/bigblog/posts/2009/12/29/number-7-problems-duke-university-healthsystem#.VZA-r_lViko; accessed 6-22-15 2:36 pm
15-year old Lewis Blackman –
2000, MUSC
Wikipedia says:
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Rhode Island = wrong side brain
surgery (x3)
Common estimates for sustained attention to a freely chosen task
range from about five minutes for a two-year-old child, to a
maximum of around 20 minutes in older children and adults.
http://en.wikipedia.org/wiki/Attention_span (accessed 1-28-14 @ 6:18pm)
58-year old Jeanette McAllister
1997, Florida
https://www.google.com/#q=pictures+of+Rhode+Island+Hospital; accessed 6-22-15 1:50 pm
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Is the healthcare industry alone?
California Commuter Train
Wreck - 2008
25 dead
http://www.msnbc.msn.com/id/34978572/ns/us_news-life/t/ntsb-blames-texting-deadly-calif-rail-crash/
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Philadelphia Amtrak - 2015
8 dead
http://nypost.com/2015/05/13/wells-fargo-exec-tech-ceo-confirmed-dead-in-amtrak-crash/; accessed 6.22.15 10:36 am
I-35W Minneapolis bridge collapse 2007
Zip line accident
Patricia – Maui, Hawaii 2014
http://mauinow.com/2014/05/01/maui-zipline-incident-under-investigation/; accessed 6-22-15 2:11 pm
http://www.findagrave.com/cgi-bin/fg.cgi?page=gr&GRid=129016466; accessed 6-22-15 2:15 pm
Number of US bridges in danger of
collapse:
>7,700
13 dead
Source: 2013 Federal analysis
http://streets.mn/2012/08/01/five-years-after-the-bridge-collapse-transportation-priorities-are-even-worse/35w-bridge-collapse/; accessed 6.22.15 10:40 am
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Massey Mine Explosion - 2010
Arizona - 2014
http://www.topicboss.com/topic/massey-coal-mine/
29 dead
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http://www.wsws.org/articles/2010/apr2010/mine-a12.shtml
http://www.cnn.com/2014/08/26/us/arizona-girl-fatal-shooting-accident/; accessed 3-5-15 4:15 pm
What we all have in common
January 21, 2011
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Fallible humans and human behaviors
Imperfect systems
Potential for faulty equipment
A set of values (individual and/or corporate)
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Great systems everywhere
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…and some not so great…
(including airport bathrooms!)
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Human Factors…
Obviously a Mom
Creating a Just Culture:
where do you start?
Just Culture definition
Workers trust each other, are rewarded for providing
safety information, and are clear about their
responsibilities regarding safe behavioral choices.
There is a shared accountability.
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Consoling – Human Error
Types of behavior involved in errors
• Human Error: an inadvertent action; inadvertently doing other
than what should have been done; slip, lapse, mistake
• A Conversation to Learn
• Help by comforting the employee
• At-Risk Behavior: a behavioral choice that increases risk
where risk is not recognized, or is mistakenly believed to be
justified
• Reckless Behavior: a behavioral choice to consciously
disregard a substantial and unjustifiable risk
• Manager also investigates the system and makes changes as
appropriate
***The employee made the mistake, not the choice
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Repetitive Human Error: Counseling
Risky Business
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Do you text and drive?
Take action:
 let the employee know that performance is
unacceptable
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It’s all about the perception of risk
Coaching at-risk behavior
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http://www.dailymail.co.uk/news/article-2127859/Like-father-like-son-Baby-Bob-Irwin-feeds-alligators-late-daddySteve-s-animal-park-aged-just-EIGHT.html
Create a learning opportunity:
- understand their point of view
- describe the at-risk behavior
- explain how this behavior isn’t aligned with our
values
- create an action plan
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Drinking and Driving – clearly Reckless
Question to ponder
Reckless Behavior is a conscious disregard of a
substantial and unjustifiable risk
Is it ever ok to knowingly violate a rule?
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>13,000 deaths per year
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Managing reckless behavior
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We need a Learning Culture
Disciplinary action
Punishment
Punitive action
Learn about errors and the behavioral choices
behind them
 Learn where the system is weak
 Learn why people drift
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Yes, I said “punitive” !!!!!
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Public perception…. or truth?
Administrative Walk-rounds
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It Happened Here
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Promotes a Just Culture
Where else should leadership spend their time?
Ask questions of employees and patients
Invite them to be a part of the solution
Provide immediate feedback
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Newsletter describing events and steps taken
to mitigate/prevent recurrence
Promotes reporting
Provides feedback (elusive in healthcare)
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Designing more reliable systems:
Creating Safer Systems
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Identify and minimize risks
Understand and accept: perfection is NOT possible
Systems can be designed to be more reliable (but
we need to be able to learn)
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Manage human factors (humans will never be perfect)
Ensure skills/competency
Standardization and protocols
Automation of tasks
Introduce barriers
Introduce redundancy
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Good: System of vehicles and
highways
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Poor system - nonsensical
Forcing functions = can’t fit
diesel nozzle
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Barriers = concrete barriers
Redundancy = frontage roads
Recovery = air bags
Error-reduction Strategies:
People
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Rules and policies
Education
Information
Performance shaping factors (checklists, reminders)
Standardization and protocols
Excellent system design
Phone below that
automatically dials
the number!
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Poor (husband) system
Investigation of Events
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Do not regard an event as “something to be fixed”
An event is an opportunity to understand risks
- system
- behavioral
Keep in mind, the system is comprised of sometimes:
- faulty equipment
- imperfect processes
- fallible humans
http://wellthisiswhatithink.com/tag/yass-mcdonalds-billboard/; accessed 6.22.15
10:50 am
Personal Performance Shaping Factors
Questions to ask
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What happened?
What normally happens?
What does procedure require?
Why did it happen?
How were you managing it?
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These must be managed when designing systems
Affect the rate of human error (and at-risk
behavior):
 Stress
 Fatigue
 Environmental
distractions
design
 Communication
 Procedural
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Scenario
Avoid Severity Bias
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Harm vs. no harm
How do you handle the situation?
“no harm, no foul” doesn’t work in a Just Culture
The NICU nurse goes to the automated cabinet to retrieve
heparin 1,000 units/ml for her patient. Without looking into
the bin, she grabs a vial. She draws up the medication and
administers it to the patient. Unbeknownst to her, the
pharmacy technician had refilled the bin incorrectly with
10,000 unit/ml heparin.
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Step 1:
Identify the undesirable outcome
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Are there more than one?
Step 2:
Begin looking for causes
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Patient given wrong
dose of heparin
What happened?
What normally happens?
What does procedure require?
RN drew up wrong med
and administered it
Step 3:
Build a cause and effect diagram
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Begin with placing the outcome(s) on the right side
of the page
Build the diagram from right to left (include all
information that could be causal)
Ensure all causes have a reasonable link to their
effect (can you prove it?)
(cause of the behavioral choice)
(behavioral choice)
RN drew up wrong med
and administered it
(human error)
Patient given wrong
dose of heparin
(outcome)
(cause of the human error)
Step 4:
Explain the human error(s)
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What behaviors were exhibited?
- Human error (any performance shaping factors
increasing chance for error?)
- At-risk
- Reckless
Every human error should have a preceding cause
(cause of the behavioral choice)
RN did not read the
label on drug
(behavioral choice)
RN drew up wrong med
and administered it
(human error)
Patient given wrong
dose of heparin
Pharmacy stocked
the drug incorrectly
(outcome)
(cause of the human error)
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Step 5:
Explain the violations
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What were the perception(s) of risk?
Every at-risk behavior should have a preceding
cause
System performance shaping factors?
Every system deviation should have a preceding
cause
Individual performance shaping factors?
Determine the causes
Probable Cause
RN always got right heparin
from this pocket; felt no
need to read label
(cause of the behavioral choice)
RN did not read the
label on drug
(behavioral choice)
Direct Cause
RN drew up wrong med
and administered it
(human error)
Patient given wrong
dose of heparin
Why?
Pharmacy stocked
the drug incorrectly
(outcome)
(cause of the human error)
Step 6:
Explain any mechanical failures
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Was it reasonable to expect this failure? Why/why
not?
Step 7:
Describe direct and potential causes
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Step 8:
Applying the Algorithm
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Remove any data that is non-causal
A caused B (direct)
A increased the likelihood of B (potential)
Ensure biases are removed
Just Culture Algorithm
Take each person involved through the Just Culture
Algorithm
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Event
Building your diagram
A nurse did not scan the wristband that was on the
patient in bed A for positive identification during a
med pass, she scanned a sticker. The patient
received bed B’s hydromorphone. The patient in
bed A had an anaphylactic response, had to be
intubated and treated with naloxone, and was
transferred to ICU. The patient fully recovered with
no permanent harm. Upon further investigation, the
nurse indicated she always keeps stickers on the
charts to use because the wristbands rarely scan.
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Outcome: patient received unauthorized medication
Human error: did not scan patient (drifting? risky?)
Cause of the human error:
 Equipment
 Find
failure
out what about the equipment failed and why
 System
 RN
not adequate
forced to create a work-around
 Find
out why
RCA2 = In the Interest of Safety
Find the causes
It is the causes of the error that give us the data we
need in order to begin to work on and build riskreduction strategies
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More name dropping…..
National Patient Safety Foundation
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
RCA2: Improving Root Cause Analyses and Actions to Prevent Harm
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Big names on the core working group and expert advisors:
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Rollin J. “Terry” Fairbanks MD, MS, FACEP, CPPS
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Director, National Center for Human Factors in Healthcare and Simulation
Training & Education Lab, MedStar Institute for Innovation, MedStar Health
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Associate Professor of Emergency Medicine, Georgetown University
John Frost
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President, Safety Engineering Services Inc.
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Member, Aerospace Safety Advisory Panel (ASAP)
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National Aeronautics and Space Administration (NASA)
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Michael R. Cohen, RPh, MS, ScD (hon), DPS (hon)
 President,
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Institute for Safe Medication Practices
John S. Carroll
 Professor
of Organization Studies and Engineering
Systems, Massachusetts Institute of Technology
 Co-Director, Lean Advancement Initiative at MIT
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Most important message:
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What this document helps you do:
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It cannot be over-emphasized that if actions resulting
from an RCA2 are not implemented and measured to
demonstrate their success in preventing or reducing
the risk of patient harm in an effective and
sustainable way, then the entire RCA2 activity will
have been a waste of time and resources.
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Download the report FREE!
Triage adverse events and close calls/near misses
Identify the appropriate RCA2 team size and membership
Establish RCA2 schedules for execution
Use tools provided to facilitate the RCA2 analysis
Identify effective actions to control or eliminate system
vulnerabilities
Develop Process/Outcome Measures to verify that actions
worked as planned
Use tools provided for leadership to assess the quality of the
RCA2 process
In the interest of equality…..
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
www.npsf.org/RCA2
YES! There were women involved in this effort! 
What does this become?
https://simple.wikipedia.org/wiki/Canada_goose; accessed 6-22-15 2:16 pm
http://www.acuteaday.com/blog/tag/goslings/; accessed 6-22-15 2:15 pm
Which then becomes….
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THIS!!!!!
Know the facts!
http://www.zdnet.com/article/scientists-channel-bird-brains-to-prevent-aircraft-collisions/; accessed 6-23-15 2:23 pm
http://icwdm.org/handbook/birds/CanadaGeese/humanhealth.aspx; accessed 6-23-15 2:27 pm
Questions – did you learn anything?
1.
2.
3.
And now FREE TIME!
T/F Severity bias should be avoided when
investigating an event.
T/F Only events with harm should be thoroughly
investigated.
Choose the correct statement(s):
a.
b.
c.
To begin a cause and effect diagram, begin with the
outcome
The outcome is the level of harm that occurred
It is the causes of the errors and behaviors that allow
us to begin to build risk reduction strategies
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