1. Redefining the Culture for Patient Safety communication collaboration education building THE FOUNDATIONS for patient SAFETY

2. Redefining the Culture for Patient Safety  A common misconception is that patient safety is about reminding people to be more careful.  But patient safety isn’t about cautioning health care staff to be more careful.  In fact, we are some of the most careful people on earth.  Improving patient safety is about changing the culture in health care from one of blame to one where we examine our systems from beginning to end to reduce the opportunities for mistakes.

3. Not Who caused the accident but What caused the accident? “Medical errors most often result from a complex interplay of multiple factors. Only rarely are they due to the carelessness or misconduct of single individuals.” Lucien L. Leape, M.D.

4. Redefining the Culture for Patient Safety Three concepts to move toward changing the culture for patient safety  Swiss Cheese Model  Blunt and Sharp End  Hindsight Bias

5. Concept 1 “Swiss Cheese Model”  Accidents result from multiple factors not a single failure  Many defenses exist to deflect failures  But, multiple failures align so error occurs  System review can help identify how failures get through the defenses

6. Swiss Cheese Model Defenses Opportunity for failure ACCIDENT System

7. Key Learnings of Swiss Cheese Model Systems that rely on error-free performance are doomed to failure Humans make mistakes Continue to strive for perfection but realize humans are not perfect

8. Concept 2 “Blunt End/Sharp End Model” Blunt End = Organization’s policies, procedures, resource allocations and systems that may contribute to an error Sharp End = Direct caregivers at source of contact with patient

9. Blunt and Sharp End Policies, procedures, resource allocation systems Blunt End Sharp End Direct caregiver Monitored Process ERROR Results

10. Key Learnings of Blunt/Sharp End The “blunt end” may be a barrier or an enabler for caregivers depending on how policies and resources are designed The “sharp end” is constantly creating ways to safeguard patients and make workaround solutions to barriers everyday

11. Concept 3 Hindsight Bias Prior to the accident/error, many intervening factors are evident and must be considered in taking action. Yet after the accident, it seems clear that a different action should have been taken. So hindsight bias is the phenomena in which how an accident/error occurred seems obvious after it has occurred.

12. Hindsight Bias Before the IncidentAfter the Incident AB B A D C Multiple Factors Seems So Easy

13. Key Learnings of Hindsight Bias Hindsight narrows the focus on the cause of the failure/incident/error without considering the whole picture, including all of the environmental, emotional, political and system issues surrounding the event Hindsight bias limits a complete and thorough investigation Hindsight bias creates a tendency to ignore system issues and focus on individual action

14. Using Concepts and Learnings Foundation for leaders to understand how errors occur Knowledge to assist leaders in creating the right safety minded culture Resources to support individual organization initiatives

15. Nonpunitive/ Blameless Culture An environment of trust is established Non-blaming, responsibility-based approach to causation of incidents/errors is created Policy for non-blame is developed Expectations for timely error and near-miss reporting and investigations are set Reporting is the norm

16. Nonpunitive/ Blameless Culture People are “rewarded” for reporting adverse events and near-misses Leadership is involved in significant investigations Learnings are based on system/process improvements Performance based accountability mechanisms are separate processes Staff involved in incidents are openly supported by leaders (caregiver guilt/grief)

17. Nonpunitive/ Blameless Culture Empower staff to correct safety hazards Leadership communicates with medical staff and employees to illustrate nonpunitive approach Language changes may reflect a positive approach to patient safety and reporting Activities of risk and legal counsel are aligned with patient safety agenda while protecting the organization

18. References/Resources Redefining the Culture for Patient Safety (www.mhhp.com) AHA Strategies for Leadership: Hospital Executives and Their Role in Patient Safety (800-242-2626 #166924) Strategies for Leadership: An Organizational Approach to Patient Safety (www.aha.org/medicationsafety)

19. References/Resources AHA Strategies for Leadership Video Series (800- 242-2626 #166921; #166922; #166923) Beyond Blame Video by Bridge Medical (www.mederrors.com) Elements of a Culture of Safety. Pennsylvania Patient Safety Collaborative (717-564-6606) AHA Quality Advisory: A Culture of Safety– Disclosure of Unanticipated Outcome Information (www.aha.org)

20. References/Resources Sample survey on culture from Allina Hospitals and Clinics (www.ismp.org/Tools/AllinaAssessment.html) Sample survey on culture from CareGroup (contact Dr. Weingart for permission sweingar@caregroup.harvard.edu) Check FHALink at www.fha.org