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!