After the Transplant: Establishing a Culture of Safety at Duke

1. After the Transplant:Establishing a Culture of Safety at Duke Karen Frush, BSN, MD Chief Patient Safety Officer Duke University Health System December 7, 2006

2. 1999 Institute of Medicine Report“To Err is Human:Building a Safer Health System” • Hospitals and healthcare agencies should establish Patient Safety Programs “to act as a catalyst for the development of a culture of safety at all levels of patient care, from frontline providers to executive leadership.”

3. LEADERSHIP PATIENTS HUMAN FACTORS RELIABILITY

4. Improving Patient Safety: Leadership Role Modeling • Leaders who are visibly committed to change traditional culture to culture of safety • Leaders, at every level of the organization, who enable staff to openly share safety information • Leaders who are trusted by staff; staff feel that their comments are heard and acted upon • Leaders drive values; values drive behavior of people who work in the organization

5. Improving Patient Safety:Apply lessons from other high risk industries, high reliability organizations • Constant “mindfulness” and preoccupation with failure • Reluctance to omit, bypass the basics • Open lines of communication • Regardless of hierarchy, title • Recognition of human limits • Design system to account for human limits • Mathematical equations and calculations

6. Improving Patient Safety: Human Factors • Majority of adverse events involve communication failure • Wrong site surgery: somebody in the room knows there’s a problem but can’t find a way to speak up • Complexity: clinical environment has evolved beyond the limitations of individual human performance

8. Error is Inevitable Because of Human Limitations • Limited memory capacity - 5-7 pieces of information in short term memory • Negative influence of fatigue and stress • Prolonged wakefulness of 18 hours causes a performance decrement approx equivalent to a blood alcohol concentration of 0.1% • Limited ability to multitask – cell phones and driving

9. Striving to Improve Patient Safety:Design Improvements into the System • Provide IT safety tools and systems: • CPOE • EMR • Smart Pumps • Highly advanced tools and system; what about the team?

10. Improving Patient Safety: Why Provide Teamwork Training? • Non-technical skills of communication and teamwork have been under-recognized and undervalued • Problems in communication account for more than 60% of Sentinel Events reported to JCAHO • Promote effective team functioning and communication to foster an environment of mutual respect • We need to speak the same language….

12. SBAR: Situational Briefing Model • Situation – the punch line 5-10 seconds • Background – the context, objective data, how did we get here • Assessment – what is the problem ? • Recommendation – what do we need to do ?

13. Why is Assertion So Hard ? • Hierarchy / power distance • Lack of common mental model • Don’t want to look stupid • Not sure I’m right • Prior experience

14. Critical Language • Key phrases understood by all to mean “stop and listen to me – we have a potential problem” • United Airlines CUS program – “I’m concerned…I’m uncomfortable…this is unsafe… I’m scared” • Duke – “ I need clarity”

15. Reporting and Disclosing Errors

16. Current Healthcare Culture • Clinicians trained in a hierarchy where mistakes are unacceptable; view an error as a failure of character: carelessness, incompetence • Board of Nursing: 3 strikes, you’re out • “Incompetent people are 1% of the problem. The other 99% are good people, trying to do a good job, who make simple mistakes. It’s the complex processes that set them up to make the mistakes” Leape, Lucian. Error in Medicine. JAMA. 1994;272:1851-1857.

17. Moving from a Culture of Blame to a Culture of Accountability • Reporting errors and adverse events • Reviewing adverse events • Identify systems issues • Identify individual choices and behaviors • Just Culture context to manage behaviors • Simple human error • Risk-taking • Blatant, reckless behavior

18. What about Disclosure:What Do Patients and Families Want After a Medical Error ? • An honest explanation • An apology • To know we’ll care for them • To know we’re doing all we can to prevent it from happening to anyone else

19. Do physicians disclose errors? • JAMA 1991: 76% of house officers had not disclosed serious error to a patient: • fear of malpractice suit; “awkward, uncomfortable” task • NEJM 2002: only 30% of respondents who experienced a medical error said that the involved healthcare professional had informed them of the error • JAMA 2005: survey of hospital leaders • 100% would disclose error causing serious harm • 85% would disclose error causing moderate harm • 45% would disclose error causing minor harm

20. Disclosure and Transparency • Non-abandonment of patients and families • No one said “I’m sorry”. Do they have any idea how it feels to be hurt by someone you thought you could trust? Do they care? • Who can I talk with to be sure they really understand the need for change? I don’t really want to go to a lawyer or the press, but what are my options? • Non-abandonment of healthcare providers • I’m a physician. If “they” have done this to me, then I’ve done this to others. • How do we help healthcare providers heal?

21. Creating a Culture of Safety:Honesty, Transparency, Disclosure • It’s hard: we have no training in disclosure • How do we help clinicians? • Leadership: we’re going there • Managers: have knowledge and tools to help • Individual clinicians: provide an example and strong support

22. Disclosure of Unanticipated Outcomes and Medical Error • Institute for Healthcare Communication • Train-the-trainer model: clinicians • Situation manager training • Disclosure team • Faculty, staff, residents, students • Coupled with team training in healthcare professional schools

23. “Nothing about me without me”