Disclosure Medication Safety, Life, and a Just Culture Natasha Nicol, Pharm D, FASHP Director, Medication Safety Cardinal Health 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. November 2010 Medicine used to be simple, ineffective, and relatively safe. Now it is complex, effective, and potentially dangerous Dept of Health and Human Services Office of Inspector General report: 1 in 7 Medicare patients experience serious harm 180,000 die each year Sir Cyril Chantler Boeing 747 450 would have to crash every year to equal medical deaths That s more than ONE A DAY! 2011 Hospital Survey on Patient Safety Culture by AHRQ (Agency for Healthcare Research and Quality) Only 44% of employees are confident they wouldn t be punished if they reported an error. 1
Anyone recognize these twins? 17 year old Jesica 2003, Duke http://www.oprah.com/health/how-a-medical-mistake-almost-killed-dennis-quaids-twins/3 http://www.oprah.com/health/how-a- Medical-Mistake-Almost-Killed-Dennis- Quaids-Twins/ http://listsoplenty.com/blog/?attachment_id=14016 http://www.ivteam.com/heparin-error-update-from-fda/ Emily Jerry 2006, Ohio Wikipedia says: 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://www.seamedical.com/?pg=errors&sl=face http://en.wikipedia.org/wiki/attention_span (accessed 7 17 12 @ 6:18pm) Rhode Island = wrong side brain surgery (x3) Is the healthcare industry alone? http://www.facebook.com/media/set/?set=a.425107597646.220578.64072902646&type=3#!/photo.php?fbid =64350537646&set=a.425107597646.220578.64072902646&type=3&theater 2
California Commuter Train Wreck 2008 BP Deepwater Horizon Oil Rig Explosion April 20, 2010 11 humans dead 25 dead http://www.msnbc.msn.com/id/34978572/ns/us_news-life/t/ntsb-blames-texting-deadly-calif-rail-crash/ http://www.psp.wa.gov/oilspills.php http://www.nasa.gov/topics/earth/features/oil_spill_initial_feature.html 13 14 Massey Mine Explosion 2010 January 21, 2011 29 dead http://www.topicboss.com/topic/massey-coal-mine/ http://www.wsws.org/articles/2010/apr2010/mine-a12.shtml 15 16 What we all have in common Fallible humans and human behaviors Imperfect systems Potential for faulty equipment A set of values (individual and/or corporate) Creating a Just Culture: where do you start? 17 18 3
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. Types of behavior involved in errors Human Error: an inadvertent action; inadvertently doing other than what should have been done; slip, lapse, mistake 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 20 Performance Shaping Factors These must be managed when designing systems Affect the rate of human error (and at risk behavior): stress fatigue environment distractions procedural design communication Managing Human Error Console the individual the error also happened to them AND Examine the system for improvement opportunities 21 22 Consoling Human Error A Conversation to Learn Help by comforting the employee The manager also investigates the system and makes changes as appropriate Repetitive Human Error: Counseling Take action: let the employee know that performance is unacceptable ***The employee made the mistake, not the choice 23 24 4
Risky Business In those states that have enacted laws against texting while driving, has the accident rate gone up or down? How are you managing your risk? Do you know your vulnerabilities? Your employees do! What At Risk behavior is occurring? At Risk Behavior is a choice: Risk believed to be insignificant or justified 25 26 It s all about the perception of risk Coaching at risk behavior 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 http://www.dailymail.co.uk/news/article-2127859/like-father-like-son-baby-bob-irwin-feeds-alligators-late-daddy- Steve-s-animal-park-aged-just-EIGHT.html 27 28 Homework List the top 3 risks in your department/business unit Describe what you are doing to manage these risks Confirm you aren t managing those risks through LUCK Question to ponder Is it ever ok to knowingly violate a rule? http://spacestaking.com/articles/surprising-junk.html 29 30 5
Drinking and Driving clearly Reckless Reckless Behavior is a conscious disregard of a substantial and unjustifiable risk Managing reckless behavior Disciplinary action Punishment Punitive action Yes, I said punitive!!!!! >13,000 deaths per year 31 32 Creating Safer Systems 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) Designing more reliable systems: Manage human factors (humans will never be perfect) Ensure skills/competency Standardization and protocols Automation of tasks Introduce barriers Introduce redundancy 33 34 We need a Learning Culture Public perception. or truth? Learn about errors and the behavioral choices behind them Learn where the system is weak Learn why people drift 35 36 6
Administrative Walk rounds 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 37 38 It Happened Here Newsletter describing events and steps taken to mitigate/prevent recurrence Promotes reporting Provides feedback (elusive in healthcare) Investigation of Events 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 39 40 Questions to ask What happened? What normally happens? What does procedure require? Why did it happen? How were you managing it? Scenario 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. 41 Choose your own adventure: a. The child was not harmed b. The child suffered severe bleeding and his survival is in question 42 7
Avoid Severity Bias Harm vs. no harm How do you handle the situation? no harm, no foul doesn t work in a Just Culture Determine the causes RN always got right heparin from this pocket; felt no need to read label (cause of the behavioral choice) Probable Cause RN did not read the label on drug (behavioral choice) Direct Cause RN drew up wrong med and administered it (human error) Why? Pharmacy stocked the drug incorrectly (cause of the human error) Patient given wrong dose of heparin (outcome) 43 Just Culture Algorithm (abbreviated) Step 1 Step 2 Step 3 Was the error/ event intentional? Yes Was the harm intentional? No No Substance abuse involved? Yes Yes Contact HR, Risk Management May need to contact authorities No Did the employee knowingly violate a policy/ procedure? Yes No Could the same event occur with another person? Was the person properly trained? Was the policy/procedure clear? Was the policy/procedure correct? Does this person have a record? 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 risk reduction strategies Visit www.justculture.org 46 The sensible Health Care Plan Discussion Natasha Nicol, Pharm D, FASHP natasha.nicol@cardinalhealth.com 47 http://media.photobucket.com/image/wile%20e%20coyote%20health%20tip/acme_armament/wile_e_coyote_health_tip_by_dalibabe9 1-d4bdjlh.jpg 4 8 8