Finding THE LIGHT IN THE TUNNEL: A NEW VIEW OF PATIENT SAFETY

1. Finding THE LIGHT IN THE TUNNEL: A NEW VIEW OF PATIENT SAFETY Sharon Jacobson, MBA, RN, CPHQ Angela Jones, MN, RN, NE-BC

2. Objectives • Describe the ‘old view’ and ‘new view’ of patient safety • Demonstrate the impact of the use of both views in clinical setting • Discuss the ‘new view’ element of psychological safety • Outline strategies teams can implement to promote a culture a psychological safety

3. Introduction Patient Safety Timeline • 2016 • End of the Strategic Plan • Balanced accountability algorithm • Physician communication training: Breakthrough communication 2012 Joined SPS(Wave 1) • 2006 • Quality and Safety 10 year strategic plan developed and approved • Key strategies: Transparency, Accountability, Data • 2014 • Watcher Program • Tandem support team • Error Prevention Training: • 2008 • Quality Resolution by TCH Board • Advanced Quality Improvement (AQI) begins 2018 Care First expansion 2004 Patient Safety Proclamation • 2010 • Vision 2010: • Epic • Feigin Center expansion • Neurological Research Center • West Campus • PFW 1999 To Err is Human 2005 First AHRQ survey 2009 • 2015 • Safety Coach Program • DOB 3.0 2003 Safety Walk Rounds 2007 Rapid Response Teams Implemented 2011 Electronic data warehouse 2013 Situational Awareness 2017 Woodlands campus Adapted from initial source provided by Dr. Joan Shook, Woodlands Orientation, Feb 2017

4. Introduction Patient Safety Timeline 2019 Safety Re-Design Adapted from initial source provided by Dr. Joan Shook, Woodlands Orientation, Feb 2017

5. Safety Story

6. Event • Patient was scheduled to receive a medication X as an outpatient • Order: Infuse medication X over 2 hours • Medication label: matched order • Infusion pump programmed to administer medication X over 2 hours • 2 hours later pump alarmed infusion was complete. Upon inspection, there appeared to be more fluid leftover in the infusion bag than expected. • Issue was researched and it was realized the wrong dose was prepared and subsequently administered. • Provider was contacted. Patient was monitored and discharged home. No apparent harm.

7. Patient story • What was the Issue/Error? • Was it preventable? • Who was at fault? • What actions should be taken to prevent event recurring?

8. Work as Imagined versus Work as Done 1st Pharmacist verifies orders Pharmacy tech prepares med 2nd Pharmacist reviews prepared med If correct, med is dispensed FINDING: Human Error - Process not followed 1st Pharmacist verified order 2ndPharmacist inadvertently prepared med incorrectly Med was dispensed Investigation: Cause was human error → Staff was coached and counseled.

9. Traditional focus on ‘Human Error’ Old View • Human error is the cause of many accidents. • The system in which people work is basically safe; success is intrinsic. The chief threat to safety comes from the inherent unreliability of people. • Progress on safety can be made by protecting the system from unreliable humans through selection, proceduralization, automation, training and discipline.

10. Old View More on….The old view perspective • Focus on humans as the cause of safety trouble and as the targets from interventions. • Simplifies the enormously complex story of how people help create safety. • Treating safety investigations as if they were individual performance reviews • Reluctance to view ‘human error’ as more about the organization than about the human (individual, team, workgroup) • Compliance with rules

11. New View

12. Human Error • “ ‘Human error’ is not just about humans. It is about how features of people’s tools and tasks and working environment systematically influence human performance.” - Sidney Dekker’s The Field Guide to Understanding “Human Error”

13. Human Error… • It is a label, a judgement/attribution made after the fact about the behavior of someone. • Sidney Dekker, The Field Guide to Understanding ‘Human Error’ • Human error is not a choice. It is an unintentional mistake. • - Todd Conklin, Pre-Accident Investigations: Better Questions

14. What is “New View” • New view looks at “human error” with a new lens • Sees “human error” as a symptom of a deeper issue • Recognizes behavior is systematically connected to features of people’s tools, tasks, and operating environment • Ask WHAT is responsible for outcome (not who) • Realizes “human error” is a starting point for further investigation (not a conclusion)

15. Old View Anatomy of an Event

16. Sees “human error” as a symptom of a deeper issue • People don’t come to work to do a bad job • People do what makes sense to them at the time…given the goals, attentional focus, and knowledge • What’s key is learning/understanding why people did what they did and why it made sense Environment Expectations Goals Training Knowledge Focus Cues Situation Experience

17. Recognizes behavior is systematically connected to features of people’s tools, tasks, and operating environment • Organizational, technological, operational features • Culture, Equipment, Environment, Policies/Procedures • Efficiency-Thoroughness Trade Offs (ETTOs) • Faster, Better, Cheaper…Conflict • Systems approach • Each part of a system plays a role in the outcome • Systems are not basically safe….people have to create safety

18. Ask WHAT is responsible for outcome (not who) • Systems are not basically safe….people have to create safety despite a system that places expectations and demands upon them. • Good processes can lead to bad outcomes and bad processes can produce good outcomes • Important to learn why things happened the way they did…if the outcome was known, things would have been done differently

19. Realizes “human error” is a starting point for further investigation (not a conclusion) • Need a culture that promotes accountability through learning • Climate of honesty, care, fairness, and a willingness to learn • Psychological safety • Avoid hindsight and outcome biases • The more you react…the less you understand • The language you use gives away where you stand • Connect actions to features of people’s tools, tasks, & environment • Promotes healing and foster communication

20. Realizes “human error” is a starting point for further investigation (not a conclusion) • Learning why things happened the way they did will aid in understanding the conditions that gave rise the problem, leading to improvement interventions focused on addressing condition… • If end point was human error…the conditions which gave rise to the problem would not be addressed

22. Safety Story

23. Event • Patient was scheduled to receive a medication X as an outpatient • Order: Infuse medication X over 2 hours • Medication label: matched order • Infusion pump programmed to administer medication X over 2 hours • 2 hours later pump alarmed infusion was complete. Upon inspection, there appeared to be more fluid leftover in the infusion bag than expected. • Issue was researched and it was realized the wrong dose was prepared and subsequently administered. • Provider was contacted. Patient was monitored and discharged home. No apparent harm.

24. Putting information in context Understanding why people did what they did… What was important to the people involved and why… What where the conditions at the time… Be aware hindsight contributes to different ways information about people’s actions gets taken out of context …

25. Putting information in context • What did the environment/situation look like at the time? • What was happening at the time? • What was going on in the process at the time? • What other tasks would people have plausibly been involved in simultaneously? • What were the goals people were trying to achieve?

26. Upon Further Investigation…the Conditions that existed for Error to take place • Pharmacy serves multiple clinical areas; location is staffed by 2 pharmacists and 1 pharmacy tech • Expectation for pharmacy is a quick turn around for meds • Monday morning – high demand for medications • EPIC was down, which is the only system this pharmacy location can use to verify orders → delaying verification of orders and medication preparation

27. Upon Further Investigation…the Conditions that existed for Error to take place • Area was backed up with medication orders • Numerous phone calls were coming in • Team working to meet the demands for medications • Second pharmacist was trying to help new pharmacist and help pharmacy tech→ Second pharmacist prepared med instead tech • Medication is not a high alert medication requiring a double check by another pharmacist

28. Patient story • What was the Issue/Error? • How did the system impact the team? • What actions should be taken to prevent event recurring?

29. In Summary… NEW VIEW OLD VIEW • *Why Did They Do • * Why Did It Make Sense • * What Were Conditions that Lead to Event • *What People Failed to Do • *What People Should Have Done to Prevent Error

30. new View… Requires people to feel safe

31. Psychological Safety Psychological Safety Psychological Safety

32. The belief that the work environment is safe for interpersonal risk taking The experience of feeling able to speak up with relevant ideas, questions, or concerns. Open and authentic communication processes that shine light on problems, mistakes, and opportunities for improvement and increases Edmondson, 2019 Psychological Safety

33. The Context of Health Care

35. Learning • Risk Management • Innovation • Job Satisfaction

36. Challenging high stakes work Crucial role of front line professionals Nested organizational structures The Context of Health Care Complexity of the setting, processes and patients High expectations to know population, be competent, not harm patient and adapt care as needed Practices in one location may not translate elsewhere

37. Hierarchal structures Powerful professional norms The Context of Health Care Perception and/or reality of limits of who can raise an issue. Expectations around autonomy; not giving feedback or critiquing others

39. https://youtu.be/LhoLuui9gX8

40. Psychological Safety

41. Psychological Safety • Individual or Group? • Positive Outcome? • Negative Outcome? • Willing to enter the ‘tunnel’ again?

42. How can we foster new view perspectives?

43. Frame the Work Model Fallibility Embrace Messengers

44. Finding the lIght in the Tunnel… • Understanding ‘old view’ and ‘new view’ of patient safety & its impact • Recognizing the importance of building psychological safety in healthcare and approaches you take to promote a culture a psychological safety

45. References • The Field Guide to Understanding Human Error. Sidney Dekker. 2014. • Pre-Accident Investigation: Better Questions. Todd Conklin. 2016. • The Fearless Organization. Amy C. Edmondson. 2019. • Safety II in Practice: Developing The Resilience Potentials. Erik Hollnagell. 2017. • Building a psychological safe workplace. Edmondson, Amy. TEDxHGSE. https://youtu.be/LhoLuui9gX8 • Understanding Human Error. Part 1. Sidney Dekker https://www.youtube.com/watch?v=Fw3SwEXc3PU • Understanding Human Error. Part 2. Sidney Dekker https://www.youtube.com/watch?v=8R8nuAqpq-g • Understanding Human Error. Part 3 Sidney Dekker https://www.youtube.com/watch?v=rUmnI3Nq3V4