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Learning From Errors Safety Culture - Reporting Systems

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Learning From Errors Safety Culture - Reporting Systems

Uploaded by

cataliao05
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Learning

From
Errors
Dr. Azza Farouk
MD, FISQua, CPPS
Definition of
Culture Merriam-
Webster Dictionary

• cul·ture
• noun \ˈkəl-chər\ : the
beliefs, customs, arts, etc.,
of a particular society,
group, place, or time
• A way of thinking,
behaving, or working
that exists in a place
or organization (such
as a business)
“How we do things here”
“What is expected here”
1. Sustainable: consistently directs the organization
toward maximum safety, regardless of leadership
personality or external pressures such as financial
2. Respect for threats that can breach various
Safety defenses
3. Informed: collects, analyzes, disseminates safety
Culture information (events, near misses, proactive
assessments)
4. Frontline engaged in reporting errors and near
misses
5. Effective management of blame and
punishment– just culture
6. Flexibility to restructure, when necessary,
• deference to expertise when appropriate
• 7. Willingness to learn
The Facesof Safety Culture

Reporting
Informed
culture
Organization culture
collects data, Employees
encouraged to report
disseminates info
safety incidents /
on hazards & risks errors without fear of
retribution

Safety Culture
Clear distinction between

Learning Just errors made in good faith


(not punishable) &
Adverse events
culture culture unacceptable behaviour
that is punishable (e.g.
analyzed thoroughly
malicious intent, gross
& organization negligence, abusive
learns how to behaviour)
prevent them Reason, J. Managing the risks of organizational accidents. 1997
Psychological
safety

• Psychological safety is a
belief that one will not be
punished or humiliated for
speaking up with ideas,
questions, concerns, or
mistakes.
• Building psychological
safety requires softening of
authority gradients
So, what does it look like?

Scenario 2 A scenario:

• Person not on top of the hierarchy – e.g.,


OR anesthesia assistant
• Something seems not quite right in
preparation for a patient’s procedure and
the patient is first on a full schedule
• Clarifying requires calling the neurosurgeon
• The OR anesthesia assistant stopped the
process and says “I need clarity”
• The case is delayed 45 minutes
6 • And it turns out that everything was OK
• What happens to her?????
In a Safety Culture: Not a Safety Culture:
• She gets thanked by the
physician. • People whisper about her.
• The manager thanks her and • She gets grief from the charge
makes sure the CEO, CNO, or
CMO come by later in the day nurse in the procedure area for
to congratulate her. messing up the entire schedule.
• Her action becomes a story • The physician demands that a
told in the organization. unit secretary cannot delay a case
again.
• She says to colleagues: “Never
doing that again.”

7
• Differentiate “at-risk behavior”
from “reckless behavior”
• Managing at-risk behaviors
requires feedback, coaching
• Reckless behaviors require
administrative consequence
• Professionalism and
Accountability Models
Accountability pyramid
Source of Errors
data
• Adverse-events/Sentinel
events reporting systems
• Claims data
• Infection rates
• Complications
• Survey results (Patient
Safety, Engagement)
Incident reporting and
learning systems
Error Reporting and Near Misses

• Provide clear expectation of what and how to


report
• Review routinely with staff
• Most importantly provide the ‘why’s’
• Give examples of important near misses
• Storytelling, Lessons Learned
Learning From Defects (Errors)

1 What happened?
From view of person involved

2 Why did it happen?

3 How will you reduce the risk of it happening again?

4 How will you know the risk is reduced?


Systems Thinking, Root Cause Analysis
Pick A Contributing Factor

Major
Contributor
Good
Intervention
Minor Target
Contributor

Occurs Occurs
Rarely Often
Prioritizing Interventions
Think low barrier/high impact matrix
High
Impact

Low
Impact

Low High
Barrier Barrier
Rank Order of Error
Reduction Strategies
Forcing functions and constraints Strongest

Automation and computerization

Standardization and protocols STRENGTH OF


INTERVENTION

Checklists and independent check systems

Rules and policies Weakest

Education and information

Vague warnings – Be more careful!


Key Takeaways
Focus on systems, not people.
Prioritize contributing factors and
interventions.
Use safe design principles.
Ask staff regularly what errors need
attention
Thanks

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