Saturday, November 28, 2009

It's a Culture of Safety...Duh!!

Ok, yes, I will admit it..when I started this blog, or rather was brainstorming it, I was a bit apprehensive, in that there are numerous blogs and websites dedicated to patient safety, so what can I offer that is interesting? I felt very much like nemo in the big ocean:-) Thereupon I decided to include caregiver safety as a part of the whole culture of safety, it could be that others have too, but I hope you all will enjoy and partner with us in this quest.

Caregivers are the link in the chain of a safety, the other big piece of the pie. The fundamental fact that was ingrained to us back in Pharmacy School, was that we are "partners in health care".. , so when then did we become foes?

More and more we are witnessing health care professionals being penalized and prosecuted for human errors that are rooted in system deficiencies. The recent post by both Bob Wachter as well as Barbara Olsen in addition to the tireless efforts of Mike Cohen of ISMP, are all testimony to the crisis that we are facing and will continue to face in health care. How then can we continue to propogate ourselves as a Culture of Safety? There are no winners here, both patients as well as their caregivers are bearing the consequences of these persecutions.

Yet, as I was browsing the net to research the dilemma of criminal prosecutions of medical/medication errors, I came upon several medical malpractice sites that are advertising to pursue litigation of health care workers, institutions and partners for victims of "medical malpractice" or negligence, as it has been termed. On the other hand, why am I not surprised to find many (if not any) potential proponents of litigation against system errors and wrongful prosecution of these health care workers and institutions? Are they also not the victims? Remember, we strove to be and are "partners in health care", yet there is a huge disparity in legal persecution among many other deficiencies as well.

So yes, we are demanding a culture of safety and yes we all take an oath to care for our patients and "Above All Do No Harm" and seem to have forgotten the rest of the Hippocratic Oath:

"I will come for the benefit of the sick, remaining free of all intentional injustice"

In our quest for a Culture of Safety, we seemed to have either overlooked or misunderstood the term "intentional"

Bob Wachter and Dr. Pronovost made an excellent case in their recent article in NEJM about balancing "no-blame" with accountability. The Just Culture model is emphasizing a similar strategy. Now let's look at the aviation industry, to which we draw constant comparisons and share lessons learned from, they have developed a great program called Crew Resource Management and there have been many discussions and papers on applying this ideology to health care. If we turn further around, we come upon the global icon in quality management, Toyota, and its 5 S  and Fishbone analysis to incorporate its A3 methodology, which again helps to delve into the root cause of problems/errors and their key criteria that there is "not" one root cause of errors, there are many direct and indirect causes as well.

So, now we know the different options available to us. Which should we adopt? In essence, we all have concluded that health care is very complex, perhaps there is no single system that is perfect for us.. in fact we might need a combination of all to create and sustain a true Culture of Safety. In this culture of harmony, we would then look at the underlying causes in the Eric Cropp case, we would want to know why the pharmacy was not staffed adequately, why an unlicensed pharmacy technician was employed in a high risk area (chemo preparation), why also the pharmacy computer system had crashed and what if any back up had been provided to Eric Cropp, a victim, also in our current Culture of Safety.

There are victims on both sides.. both partners in care are suffering, no one is satisfied- and our legal system, the media and organizations are relentlessly pursuing persecution. I am still in many ways a novice in this arena and am extremely grateful to the many authors, patient safety organizations and health care quality devotees like myself, that are consistently educating me as well as my peers. Bob Wachter in his blog has repeatedly emphasized the need for us, the health care field, both the patient and the caregivers, to take charge of our system of accountability before it is too late!! The way I see it, following are some of my (humble) recommendations:

1. Create a team/system of legal proceedings that has indepth knowledge and expertise of the health care dynamics and can address the needs of both the partners..patients and caregivers- They can serve as consultants and provide the framework for a "just & fair health care system"
2. Create a national transparent system of accountability for health care errors, both medical and non-medical
3. Develop a national framework for ensuring a Culture of Safety- harmony and partnership for both, the patient and the caregiver, partners in health care

Let us be proactive and take charge in saving both our patients and their caregivers, so we can prevent harm and save lives. In parting, I would welcome any suggestions and comments.. as mentioned earlier the learning process is always ongoing:-)

Until later, Stay Safe!!!

Win through your Actions, Never through Argument  
( 48 laws of power)

Friday, November 6, 2009

Aviation vs Health Care: The Age Long Dilemma of Comparisons

Comparing our industry to aviation, has been a discussion in almost all patient safety groups and initiatives. Recently the event of a Northwest plane that missed landing for about 150 miles as well as the incident with an Australian airline, where the pilots forgot to load the landing gear prior to landing and had to climb back up and re-attempt landing the plane, all these have made one thing clear, there are weaknesses to be addressed in both systems. No one of us is perfect, we are all a work in progress, yet we draw constant comparisons to each other.

The point of discussion here would be the action taken by management to these incidents. In both of the cases mentioned above, there are reports of the pilots being suspended awaiting an investigation. Again, a classic example of a "culture of blame".

Yesterday, I was most fortunate to attend a webinar by ASHP with speakers from ISMP and Outcome Engineering, among others. For those of you who don't know, David Marx from Outcome Engineering, is the pioneer and innovator of the Just Culture concept. It was truly quite an engaging and learning experience, which focused on three kinds of behaviors:

Human Error
At Risk Behavior and
Negligent Behavior (

The summary and conclusion of the webinar was really simple, first we need to look at the systems we work with, discover if there were any weaknesses or latent factors in the system that could have contributed to the error, and then we focus on the individual behavioral choices to determine if the individual made a conscious decision to disregard known policies and procedures. One of the questions I had asked and frequently ponder, is the comparison of this analogy to that of James Reason and his Decision Tree (
). In essence, the distinction between both is really that for the latter model, an adverse outcome has already occurred, whereas the Just Culture, takes into consideration all events, regardless of outcomes. In other words, even if the patient did not suffer any harm, the Just Culture model helps us determine the cause of actions as well as individual contribution to the error. It basically is a Fair and Transparent model.

One that we should all embrace, regardless of which industry we come from, or which model we follow, this type of model allows for continuous quality improvements and prevention of harm.

While I have no direct association with either Outcome Engineering, ASHP or ISMP, the fact that Captain Sullenberger was carrying the Just Culture book with him during that eventful day where he saved the lives of scores of people by landing his plane safely on the Hudson, should allow us a moment to consider what is being recommended by a national hero!

Till we meet again, Stay Safe!

Wednesday, October 14, 2009

Above all do no harm; but what if the harm is unintentional?

Ever since the IOM's infamous report in 1999; To Err is Human, there have been numerous reports of both medical and medication errors. In my frequent presentations on Medication Safety, I have talked and educated about quite a few of them. In most cases, a root cause analysis was performed along with system analysis as well as individual staff duties and performances. Various legislative recommendations have been made, including the AHRQ list of "never events". The underlying emotion in all the cases that I reviewed was both sympathy and guilt by the individuals involved in these cases. I am quite sure, as most of you will agree with me, that no one goes to work planning to make a medication or medical error. Regardless of what discipline we are specialized in, we are health care workers. We all embrace the Hippocrates oath and want to take care of our patients, want to do a good job, so that at the end of our work we go home happy, content and with a good conscience.

Unfortunately we are seeing more "criminalization of health care", as David Marx puts it. The human error concept of errors is still taught, preached, but alas not practiced much anymore. These well meaning professional individuals, that were for so long providing "quality patient care" are now being penalized and in some cases convicted and sentenced with corresponding jail time. While I am sure many of us cannot even begin to imagine the horror, pain and suffering of the families of the patients, however penalizing individuals for human error caused due to system failures, breakdowns in communication and uncontrollable human factors, will not solve the problem. Rather in my humble opinion, will create a bigger one. Dr. Cohen has already eluded to it in his excellent article :

"An injustice has been done: Jail time given to a Pharmacist who made an error"- ISMP.

On the other hand, when I read about the efforts of the Josie King Foundation and the Quaid Foundation, not only am I deeply humbled, but proud as well. This is our nation, our society, our communities, that come together in times of despair and tragedy, and work together to ensure that the same mistakes are not repeated again. That no other child or family should have to suffer in silence again. The Josie King Foundation helped create a condition H in hospitals, that allows family members to alert caregivers when they are concerned about the health of the patient. The Quaid foundation is working with companies and health care quality organizations to ensure proper labeling of drugs. There are many more stories out there of families that came together and are joining hands with us, the health care workers, to ensure patient safety.

That is what we hope to achieve, make a safer health care system for both our patients and caregivers.

When David Marx introduced his concept of Just Culture, I felt liberated! At last, there is a system that will be more proactive than reactive. However, I too, much like Dr. Cohen, am becoming more concerned about these convictions. The results will most likely a decrease in error reporting for fear of reprisals; why report if we are going to lose our jobs, livelihood, after all nothing has happened to the patient yet. My question is, are we then going to wait for something to happen to another patient or are we going to help create a culture of trust among both patients and caregivers? As David Marx wisely put it, we are creating a "culture of blame"-how are we ever going to master a culture of patient safety?

Hence, safety voyagers, here is my first attempt at writing, recognizing the partnership of our health care workers AND our patients..

We are one!

Monday, October 12, 2009

Welcome Aboard Safety Voyagers!

While there are many blogs and sites discussing the need and importance of patient safety, I would like to offer a fresh approach to it by including the need to recognize a systems approach to both patient and caregiver safety along with prevention of errors.

The Just Culture concept by David Marx and the Human Culpability decision tree by James Reason are excellent tools for us to merge these two crucial value chains in the health care field. I hope we can all benefit from this interface and welcome all and any comments as well.

Stay Safe!!

“It must be considered that there is nothing more difficult to carry out, nor more doubtful of success, nor more dangerous to handle, than to initiate a new order of things”
                                                                                               Nicolo Machiavelli 1469-1527