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Creating a Just Culture
Christine Young, MSN, MBA, RN April 23, 2014
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Objectives Discuss the prevalence of medical errors and contributing factors Define the Just Culture Model and discuss key concepts Explain use of the Incident Decision Tree when evaluating behavior Apply the Incident Decision Tree process to clinical examples
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Medical Errors Mistakes made in the process of care that result in or have the potential to result in harm to patients Result of action that is taken (commission) or an action that should be taken but is not (omission) Often the result of many contributing factors and local triggers, not a single action or event Harm often occurs when multiple organizational defenses fail
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Sept 14, 2010 at Seatte Children’s Hospital
24 year career in nursing Had cared for this baby in the past Administered 1.4 grams of calcium chloride instead of 140 milligrams-died 5 days later Reported it herself “I was talking to someone while drawing it up. Miscalculated in my head the correct mls according to the mg/ml. First med error in 25 years of working here. I am simply sick about it.” Only serious medical mistake she ever made Hiatt was fired, there was a state nursing commission investigation Committed suicide in April
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Kaia
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Prevalence of Medical Errors
IOM (2000) Report 44,000-98,000 annual deaths resulting from errors Medical errors are leading cause, then surgical errors 7% of hospitalized patients experience a serious medication error Associated costs $8-29 billion US Department of Health & Human Services (2010) reports 180,000 death/year due to preventable medical error
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JCAHO Sentinel Events Root Causes Communication problems
Orientation/Training Patient Assessment
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Contributing Factors Workload fluctuations Interruptions Fatigue
Multi-tasking Failure to follow up Poor handoffs Ineffective communication Not following protocol Excessive professional courtesy Halo effect Passenger Syndrome Hidden agenda Complacency High risk phase Strength of an idea Task fixation Excessive courtesy-higher rank or status Halo effect – reputation Passenger syndrome-”someone else is in charge” Hidden agenda – get done early High risk phase – such as change of shift/handoff Strength of an idea-strong belief, inability to see other possibilities Task fixation – focused on task, pressure to perform, fail to see big picture.
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Accountability Evaluation of performance and responsibility Components
Individual’s understanding they are to perform an action Clear expectation as to what that action is The means of evaluating the action
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An error occurs….What Now?
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“The single greatest impediment to error prevention is that we punish people for making mistakes.”
Dr. Lucian Leape Harvard School of Public Health
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Previous Models of Accountability
Punitive Culture Pre-1990’s Manage risk and errors by frequent directives to work carefully Retraining, counseling, threat of discipline Individuals accountable for outcomes Perfect performance expected and achievable Severity of discipline = severity of outcome Resulted in opposite effect Errors not reported Prevented analysis of system problems
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Previous Models of Accountability
Blame-Free Culture Mid-1990’s Culture shift to “no-blame” Acknowledged human fallibility Mistakes rooted in system, process, technical or environmental issues in the organization Recognition that honest mistakes were not blameworthy Fails to confront those who willfully and repeatedly make unsafe behavioral choices Endangers patients and opposes workers’ sense of justice
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What is Just Culture? Emerged in the 2000’s Developed by David Marx
Used in aviation industry A model to improve patient safety Creates a positive environment for reporting risk or mistakes Well-established system of shared accountability: system design and individual behaviors
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What is Just Culture Reconciles “no blame” and accountability
Structured approach to response Does not depend on the potential or actual severity of the outcome of the error Recognizes responsibility of health care providers to follow established safe practices
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Cornerstones of Just Culture
Create a Learning Culture Create an Open and Fair Culture Design Safe Systems Manage Behavioral Choices Without learning, make same mistakes Middle ground between punitive and blame free Reduce opportunity for human error; capture errors early and allow recovery Humans will make mistakes and cultures will drift into unsafe practices, manage behavior to achieve outcomes
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Rationale for Use Balances the assessment of systems, processes and human behavior Creates an environment where negligence is identified and discipline is applied appropriately after systematic review Organizations are accountable for system processes and staff are accountable for their actions
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Goals of Just Culture Design safe systems that will reduce the opportunity for human error and catch errors before they reach the patient Less focus on events, errors and outcomes More focus on risk, system design and behavioral choices Encourage reporting of events and near- misses to identify and fix system processes before actual harm
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High Reliability Teams
Teams that perform consistently over time with the same quality results Carry out complex and risky work Three components of Highly Reliable Teams Identify Error – Simulation Testing of Processes Mitigate Error – Teamwork Training and Coaching Manage Error – Just Culture focused on Behavior
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Behaviors Human Error At Risk Behavior Reckless Behavior
Inadvertent action, doing other than what should have been done; slip, lapse, mistake At Risk Behavior Behavioral choice that increases risk where perception of risk is lost or is mistakenly believed to be justified May be result of cultural norms or standardization of deviance Reckless Behavior Behavioral choice to consciously disregard a substantial and unjustifiable risk
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Outcomes Human Error At Risk Behavior Reckless Behavior
Product of current system design Redesign the system to prevent further errors Console and learn At Risk Behavior Risk believed to be insignificant or justified Uncover the unsafe habits and remedy system based reasons Decrease staff tolerance Coach and check Reckless Behavior Conscious disregard of unjustifiable risk Manage through disciplinary action
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Really, officer, I had no idea!
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Just Culture Application
Human Error You are preoccupied with work issues from the day. You are driving home and when you see the flashing lights you look at the speedometer and it says 80mph and the speed limit is 60mph. At-Risk Behavior You are late to your son’s football game. You decide to drive faster (80 mph in a 60 mph zone) to make it in time for kickoff. Reckless Behavior You decide you are not missing kickoff for any reason and drive 80mph, switching lanes frequently, cutting off other drivers, all while texting your son to let him know you are on your way.
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Event Investigation What happened? What normally happens?
What does procedure require? Why did it happen? How were we managing it?
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5 Just Culture Rules Causal statements should clearly show cause and effect relationship Negative descriptors (ie poorly) may not be used in causal statements Each human error should have a preceding cause Each at-risk behavior should have a preceding cause Failure to act is only causal when there is pre-existing duty
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Just Culture Algorithm
Decision-making pathway Assists with assessment of behavior as human error, at risk or reckless Provide suggestion for response
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Incident Decision Tree
Developed by The National Patient Safety Agency in the UK Provides a framework for objectively assessing an individual’s actions, motives and behavior
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Four Tests Deliberate Harm Test Incapacity Test Foresight Test
Were the actions intended? Incapacity Test Was the employee impaired? Foresight Test Did the employee depart from agreed protocols or safe procedures thus increasing risk? Substitution Test Would another comparable employee behave in the same way in similar circumstances?
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Applying Accountability
Individual Accountability: Deliberate Harm: Discipline Incapacity: Medical Leave/EAP Foresight: Training, Supervision, Coaching System Accountability Substitution Test: Performance Improvement
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Errors in the Health Care Environment
Unpredictable, high risk events are the norm Complex teams Environment vulnerable to medical errors Liability issues
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Risks in Health Care Environment
Use of High Alert Medications Surgical Safety Emergency Management Interpretation of Data Complex communication structure High risk, low use procedures
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Jasmine Gant 2006 16 year old in labor & delivery at St. Mary’s Hospital in Madison Wisconsin Nurse Julie Thao mistook an infusion bag of epidural medication for penicillin Administered the epidural meds into Jasmine’s IV instead of the penicillin Jasmine suffered cardio-pulmonary arrest and died The baby was delivered via emergency c-section and survived Julie was fired and later prosecuted by the state of Wisconsin for criminal negligence She too also contemplated suicide, but was asked to be a patient-safety fellow and she now does patient safety research
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Jasmine Gant Case ISMP investigation concluded that “while the nurse bypassed multiple safety procedures, there were also system flaws that allowed and even encouraged her to do so, contributing to the fatal error.”
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Nurse Accountability Nurse did not apply ID band
Nurse did not use the hospital’s barcoding system Both medications were brought to the room at the same time and before orders were given Nurse had worked two consecutive 8 hour shift the day before, slept at the hospital and came on duty the next morning
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Organizational Accountability
Bar Coding system had glitches Nurses were not adequately trained and many often bypassed the system No rules to prevent nurses from becoming fatigued
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Just Culture Analysis Were the actions or consequences intended?
No Was the individual impaired? Fatigue Did the individual depart from policies and procedures? Yes Would another individual behave in the same way in similar circumstances?
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Caring for the Caregiver
Medical errors are devastating for the caregiver Investigations, Root Cause Analysis Loss of job, income, license Criminal charges Emotional responses-anxiety, depression, thoughts of suicide NQF’s Caring for the Caregiver standard Formal support systems and treatment for traumatized caregivers related to errors
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