Date post: | 15-Apr-2017 |
Category: |
Health & Medicine |
Upload: | psow |
View: | 1,787 times |
Download: | 0 times |
Culture of Safety
• 80% of medical errors are system‐derived• Good people simply working harder will not be sufficient to overcome the high complexity inherent in EMS.
• Errors will occur• The key is to design systems so that harm does not reach the patient.
Reason’s "Swiss Cheese" Model
Reason, James. Human error: models and management. British Medical Journal 2000; 320:768‐770.
Culture of Safety
• The benefit of this approach to managing behavior is that the process is up‐front and transparent to the staff, which helps to achieve trust.
• Risks become identified, reckless behavior isn’t tolerated, and ultimately the organization is safer.
• In practical terms, today you are 3x more likely to be involved in a MVC and 1,000x more likely to be involved in a medical error than in an aviation‐related incident, due in part to this cultural shift.
An Introduction to Just Culture
The single greatest impediment to error prevention in the medical industry is
“that we punish people for making mistakes”
Dr. Lucian LeapeProfessor, Harvard School of Public Health
Testimony before Congress on Health Care Quality Improvement
Safe Culture• The first and possibly most important step in promoting a safe
culture is the establishment of justice.– Just Culture – A system of shared accountability– The organization is responsible for safe system and process design– And employees are responsible for safe choices and behaviors
• This shifts an organization away from a “blame” culture. • Why? • Because to design safety, the organization needs feedback from
users (employees). • To give feedback, employees need trust. • An organization can establish this trust through a consistent and fair
approach to managing employee behaviors.
Establishment of a Just Culture• Outcome Engineering of Plato, Texas defines these three
behaviors as follows:• Human Error:
– An inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake.
– Product of current system design and behavioral choices• At‐Risk Behavior:
– A behavioral choice that increases risk where risk is not recognized, or is mistakenly believed to be justified.
– A choice, risk believed insignificant or justified• Reckless Behavior:
– A behavioral choice to consciously disregard a substantial and unjustifiable risk.
Establishment of a Just Culture
• Human Error: – An inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake.
– Product of current system design and behavioral choices
• Manage through changes in:– Processes & Procedures– Design– Training
• Console
Establishment of a Just Culture
• At‐Risk Behavior: – A behavioral choice that increases risk where risk is not recognized, or is mistakenly believed to be justified.
– A choice, risk believed insignificant or justified • Manage through:
– Removing incentives for at‐risk behaviors– Creating incentives for healthy behaviors– Increasing situational awareness
• Coach
Requires A Change in Culture
“Treat every drug administration as if it’s wrong and will kill the patient”
John Nance
• Suggested Meds:– Narcotics, to include Ketamine – Epi 1:1,000 vs Epi 1:10,000– Mag Sulfate– Any Pediatric Dose– Rarely used medications [Diltiazem]– All CCP medications
Establishment of a Just Culture
• Reckless Behavior: – A behavioral choice to consciously disregard a substantial and unjustifiable risk
• Manage through:– Remedial action– Punitive action
• Discipline
Accountability for Our BehaviorsHuman Error At‐Risk Behavior Reckless Behavior
Inadvertent action: slip, lapse, mistake
A choice: risk not recognized or believed justified
Conscious disregard of unreasonable risk
Manage through changes in:• Processes• Procedures• Training• Design• Environment
Manage through:• Remove incentives
for at‐risk behaviors
• Create incentives for healthy behaviors
• Increase situational awareness
Manage through:• Remedial action• Punitive action
Console Coach Discipline/Sanction
Just Culture – Not BlameAlso not carefree
• A just culture recognizes that individual practitioners should not be held accountable for system failings over which they have no control.
• A just culture also recognizes many errors represent predictable interactions between human operators and the systems in which they work; and recognizes that competent professionals make mistakes.
• Also acknowledges that even competent professionals will develop unhealthy norms (shortcuts, “routine rule violations”).
• A just culture has zero tolerance for reckless behavior.
Wrong Medication DoseHuman Error At‐Risk Behavior Reckless Behavior
Inadvertent action: slip, lapse, mistake
A choice: risk not recognized or believed justified
Conscious disregard of unreasonable risk
“I drew up 4mg and gave it IV, then immediately realized that it should have been 0.4 mg”
“I would have double‐checked with my partner, but she was out getting supplies, and I wanted to get the patient treated”
“I have everything memorized and don’t rely on cheat sheets and can’t trust another medic”
Console Coach Discipline/Sanction
Wrong Medication DoseHuman Error At‐Risk Behavior Reckless Behavior
Inadvertent action: slip, lapse, mistake
A choice: risk not recognized or believed justified
Conscious disregard of unreasonable risk
“I drew up 4mg and gave it IV, then immediately realized that it should have been 0.4 mg”
“I would have double‐checked with my partner, but she was out getting supplies, and I wanted to get the patient treated”
“I have everything memorized and don’t rely on cheat sheets and can’t trust another medic”
Console Coach Discipline/Sanction
Wrong Medication DoseHuman Error At‐Risk Behavior Reckless Behavior
Inadvertent action: slip, lapse, mistake
A choice: risk not recognized or believed justified
Conscious disregard of unreasonable risk
“I drew up 4mg and gave it IV, then immediately realized that it should have been 0.4 mg”
“I would have double‐checked with my partner, but she was out getting supplies, and I wanted to get the patient treated”
“I have everything memorized and don’t rely on cheat sheets and can’t trust another medic”
Console Coach Discipline/Sanction
RSI: Paralysis Without SedationHuman Error At‐Risk Behavior Reckless Behavior
Inadvertent action: slip, lapse, mistake
A choice: risk not recognized or believed justified
Conscious disregard of unreasonable risk
“3 am call, very busy night, I was tired”
“Patient had a head injury and was unconscious so didn’t need sedation”
“Patient is demented and won’t remember anyway” or “I’ve never had a patient complain”
Console Coach Discipline/Sanction
RSI: Paralysis Without SedationHuman Error At‐Risk Behavior Reckless Behavior
Inadvertent action: slip, lapse, mistake
A choice: risk not recognized or believed justified
Conscious disregard of unreasonable risk
“3 am call, very busy night, I was tired”
“Patient had a head injury and was unconscious so didn’t need sedation”
“Patient is demented and won’t remember anyway” or “I’ve never had a patient complain”
Console Coach Discipline/Sanction
RSI: Paralysis Without SedationHuman Error At‐Risk Behavior Reckless Behavior
Inadvertent action: slip, lapse, mistake
A choice: risk not recognized or believed justified
Conscious disregard of unreasonable risk
“3 am call, very busy night, I was tired”
“Patient had a head injury and was unconscious so didn’t need sedation”
“Patient is demented and won’t remember anyway” or “I’ve never had a patient complain”
Console Coach Discipline/Sanction
Accountability for Our BehaviorsHuman Error At‐Risk Behavior Reckless Behavior
Inadvertent action: slip, lapse, mistake
A choice: risk not recognized or believed justified
Conscious disregard of unreasonable risk
Manage through changes in:• Processes• Procedures• Training• Design• Environment
Manage through:• Remove incentives
for at‐risk behaviors
• Create incentives for healthy behaviors
• Increase situational awareness
Manage through:• Remedial action• Punitive action
Console Coach Discipline/Sanction