Learning to Learn From Patient Safety Events

1. Learning to Learn From Patient Safety Events Knowledge Exchange Workshop, Nov. 2nd, 2010 g Winnipeg Regional Health Authority f Measuring Learning at the Patient Care Unit Level Research funded by the Canadian Institutes of Health Research http://www.yorku.ca/patientsafety/

2. Outline • PSE Learning study summary • Can we only learn from Catastrophe? • Is there variation in learning from PSEs across Ontario hospitals? • What factors influence PSE learning? http://www.yorku.ca/patientsafety/

3. 1. Learning from Patient Safety EventsStudy Background • 3-year, 2-phase study: • P1. To understand what kind of PSEs are relevant to staff and managers in daily practice • P1. Develop PSE Learning Instrument • P2. What factors influence learning from PSEs http://www.yorku.ca/patientsafety/

4. to err is human to cover up is unforgivable to fail to learn is inexcusable -Sir Liam Donaldson Chief Medical Officer UK Department of Health http://www.yorku.ca/patientsafety/

5. The universe of PSEs Dimensions of PSE LearningRoots: theoretical models of learning from failure (Argote 1999 Identification Identify and bring PSEs to the attention of others Analysis Properly analyze the system-level causes of PSEs Smaller numbers of PSEs subject to each stage of the learning process Change Put corrective strategies in place to reduce PSE reoccurrence; monitor change to ensure it’s sustained Dissem- ination Communicate and disseminate information learned above to others on the unit / in the organization The universe of PSEs Based on Failure-induced learning theory: Sasou, K., and J. Reason. 1999. ‘‘Team Errors: Definition and Taxonomy.’’ Reliability Engineering and System Safety, 65 (1): 1–9. Argote, L. 1999. Organizational Learning: Creating, Retaining and Transferring Knowledge. Norwell: Kluwer. http://www.yorku.ca/patientsafety/

6. Matryoshka DollsLearning from patient safety events takes place in only a very small subset of events http://www.yorku.ca/patientsafety/

7. Analysis Change Dissem 4. Recognized, discussed and reported: A – in the chart B – to a paper or on-line IR system C – to person / team with mandate & resources to investigate and make change 1. Safety incidents A B 5. Recognized, and locally investigated C 2. Recognized safety incidents 3. Recognized and discussed incidents http://www.yorku.ca/patientsafety/

8. But we learn differently from different types of PSEs… • The following typology: • Emerged from focus groups with front-line staff and managers • Describes how these front-line groups naturally group PSEs • Seen as meaningful for understanding everyday practice http://www.yorku.ca/patientsafety/

9. Near Misses have the potential to cause varying degrees of harm from none to very serious (near misses can be caught far from to very close to the patient) Grey areas representing events between categories Arrows reflect increasing severity of the events (red) and near misses (green) Typology of Patient Safety Events Minor Event Major Event Moderate Event Minor Near Miss Events can cause varying degrees of harm from none to very severe Major Near Miss Definition: An event that would have resulted in no harm or very minimal temporary harm to the patient but did not because it was caught or because of good luck. Examples: Noticing that you have dispensed extra-strength Tylenol when Tylenol 2 was ordered Definition: An event involving no harm or very minimal temporary harm to the patient. Examples: Administering Extra-strength Tylenol instead of Tylenol 2’s; a missed suppository and patient suffers one day of mild constipation; staff forgets patient’s appointment for seating servicing and a patient must wait another week for a new chair Definition: An event that causes discomfort sufficient to interfere with usual activity and requires additional specific therapeutic intervention but, poses no significant or permanent risk of harm to the patient. Examples: Post stroke patient on dysphagic diet is given thin fluids and aspirates resulting in pneumonia, resolves with treatment Definition: An event that would have resulted in death or serious physical or psychological injury but did not because it was caught or because of good luck. Examples: Interrupted attempted suicide by hanging, wrong patient is sent for a surgical procedure and is discovered in the OR Definition: An event involving death or serious physical/psychological injury. These events should not be considered ‘stuff’ that ‘just happens’. Nor should they be considered inevitable. Examples: Unanticipated death or major permanent loss of function; suicide; hemolytic transfusion reaction involving administration of blood; surgery on the wrong patient or wrong body part. http://www.yorku.ca/patientsafety/

10. Practically speaking… • the goal is to grow the size of the smallest matryoshka doll • and also recognize that we learn differently from different types of PSEs… • For minor events, the largest matryshka doll (the universe of events) would be enormous and the smallest (Actual learning) would be tiny http://www.yorku.ca/patientsafety/

11. The PSE Learning Checklist • Concrete set of learning behaviours that can function as a checklist following different types of PSEs … that are identified http://www.yorku.ca/patientsafety/

12. What learning behaviors do we engage in most often…least often? http://www.yorku.ca/patientsafety/

13. % engaging in learning response “always/almost always” OR “usually” http://www.yorku.ca/patientsafety/

14. % engaging in learning response “always/almost always” OR “usually” http://www.yorku.ca/patientsafety/

15. Support at all Levels - “Squeezed in the middle” - “In our experience, most boards and leaders overestimate the frontline staff’s ability to improve. In such cases, even with sufficient will and great ideas…execution stalls” (Conway, 2008)  Single-loop learning – quick fixes  Double-loop learning – correcting the underlying causes of a problem http://www.yorku.ca/patientsafety/

16. 2. Can we only learn from Catastrophe? http://www.yorku.ca/patientsafety/

17. 3.61 2.88 Dissem Analysis 1.Can we only learn from Catastrophe?Learning Responses to 4 types of PSEs 4-Always 3-Usually 2-Sometim 1-Never Event learning n=54 Event learning Event learning Event learning http://www.yorku.ca/patientsafety/

18. 3. Is there variation in learning from PSEs across hospitals? http://www.yorku.ca/patientsafety/

19. Minor event learning scores for 54 Ontario hospitals 4-Always 3-Usually 2-Sometim 1-Never http://www.yorku.ca/patientsafety/

20. Major event Analysis learning scores for 54 Ontario hospitals 4-Always 3-Usually 2-Sometim 1-Never http://www.yorku.ca/patientsafety/

21. Major event Dissemination learning scores for 54 Ontario hospitals 4-Always 3-Usually 2-Sometim 1-Never http://www.yorku.ca/patientsafety/

22. 4. What factors influence learning from Patient Safety Events? http://www.yorku.ca/patientsafety/

23. Factors that influence learning from PSEs • Functional diversity of the unit (invU-shape) • Type of PSEs • Manager PS training • Inter-organizational linkages • Psychological safety & fear of repercussions • Ease of reporting (+ with low fear only) • Formal organizational leadership for PS ++ http://www.yorku.ca/patientsafety/

24. Organizational Leadership for PS and Learning from PSEs http://www.yorku.ca/patientsafety/

25. So…in 3 years we found out… • Practically speaking F-L staff and managers think in terms of straightforward, pretty clear cut event types • There are a series of concrete learning responses that organizations and units can and should be engaging in to reduce reoccurrence of PSEs • But the complete learning process is found only in the smallest Matryoshka doll • We do more in response to catastrophes • But some organizations do a lot more than others • And we can identify some factors that → learning http://www.yorku.ca/patientsafety/

26. … Using PSE Learning Checklist • Comparison over time • Starting conversations • Do the PSE learning instrument with the right people: assess current practice • Take the results (and process?) up and down the organization: goal setting • Getting CEOs involved through an in-depth PSE case study (Conway, 2008) • PSE Learning instrument concrete tool to reduce the knowing-doing gap (Pfeffer & Sutton, 2000): action reduces this gap http://www.yorku.ca/patientsafety/

27. References Ginsburg, L., Y. Chuang, P.G. Norton, W. Berta, D. Tregunno, P. Ng, J. Richardson. (2010). The relationship between organizational leadership for safety and learning from patient safety failure events. Health Services Research. [Epub ahead of print] Ginsburg, L., Y. Chuang, P.G. Norton, W. Berta, D. Tregunno, P. Ng, J. Richardson. (2009) “Development of a Measure of Patient Safety Event Learning Responses”. Health Services Research. 44(6): 2123-2147.. Ginsburg, L.R., Y. Chuang, J. Richardson, P.G. Norton, W. Berta, D. Tregunno, P. Ng. Categorizing Errors and Adverse Events for Learning: The provider perspective. (2009) Healthcare Quarterly, 12:154-160. Chuang, Y., Ginsburg, L., Berta, W. (2007). Learning from preventable adverse events in health care organizations: development of a multilevel model of learning and propositions. Health Care Management Review, 32(4). http://www.yorku.ca/patientsafety/ http://www.yorku.ca/patientsafety/