Transcript When Bad Things Happen to Good Nurses

Christine Young, MSN, MBA, RN
April 23, 2014
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Discuss the prevalence of medical errors and
contributing factors
Define the Just Culture Model and discuss key
concepts
Explain use of the Incident Decision Tree
when evaluating behavior
Apply the Incident Decision Tree process to
clinical examples
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Mistakes made in the process of care that
result in or have the potential to result in
harm to patients
Result of action that is taken (commission) or
an action that should be taken but is not
(omission)
Often the result of many contributing factors
and local triggers, not a single action or event
Harm often occurs when multiple
organizational defenses fail
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IOM (2000) Report
◦ 44,000-98,000 annual deaths resulting from errors
◦ Medical errors are leading cause, then surgical
errors
◦ 7% of hospitalized patients experience a serious
medication error
◦ Associated costs $8-29 billion
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US Department of Health & Human Services
(2010) reports 180,000 death/year due to
preventable medical error
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Root Causes
◦ Communication problems
◦ Orientation/Training
◦ Patient Assessment
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Workload fluctuations
Interruptions
Fatigue
Multi-tasking
Failure to follow up
Poor handoffs
Ineffective
communication
Not following protocol
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Excessive professional
courtesy
Halo effect
Passenger Syndrome
Hidden agenda
Complacency
High risk phase
Strength of an idea
Task fixation
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Evaluation of performance and responsibility
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Components
◦ Individual’s understanding they are to perform an
action
◦ Clear expectation as to what that action is
◦ The means of evaluating the action
“The single greatest impediment to error
prevention is that we punish people for
making mistakes.”
Dr. Lucian Leape
Harvard School of Public Health
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Punitive Culture
◦ Pre-1990’s
◦ Manage risk and errors by frequent directives to
work carefully
◦ Retraining, counseling, threat of discipline
◦ Individuals accountable for outcomes
◦ Perfect performance expected and achievable
◦ Severity of discipline = severity of outcome
◦ Resulted in opposite effect
◦ Errors not reported
◦ Prevented analysis of system problems
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Blame-Free Culture
Mid-1990’s
Culture shift to “no-blame”
Acknowledged human fallibility
Mistakes rooted in system, process, technical or
environmental issues in the organization
◦ Recognition that honest mistakes were not
blameworthy
◦ Fails to confront those who willfully and repeatedly
make unsafe behavioral choices
◦ Endangers patients and opposes workers’ sense of
justice
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Emerged in the 2000’s
Developed by David Marx
Used in aviation industry
A model to improve patient safety
Creates a positive environment for reporting
risk or mistakes
Well-established system of shared
accountability: system design and individual
behaviors
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Reconciles “no blame” and accountability
Structured approach to response
Does not depend on the potential or actual
severity of the outcome of the error
Recognizes responsibility of health care
providers to follow established safe practices
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Create a Learning Culture
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Create an Open and Fair Culture
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Design Safe Systems
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Manage Behavioral Choices
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Balances the assessment of systems,
processes and human behavior
Creates an environment where negligence is
identified and discipline is applied
appropriately after systematic review
Organizations are accountable for system
processes and staff are accountable for their
actions
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Design safe systems that will reduce the
opportunity for human error and catch errors
before they reach the patient
Less focus on events, errors and outcomes
More focus on risk, system design and
behavioral choices
Encourage reporting of events and nearmisses to identify and fix system processes
before actual harm
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Teams that perform consistently over time
with the same quality results
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Carry out complex and risky work
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Three components of Highly Reliable Teams
◦ Identify Error – Simulation Testing of Processes
◦ Mitigate Error – Teamwork Training and Coaching
◦ Manage Error – Just Culture focused on Behavior
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Human Error
◦ Inadvertent action, doing other than what should
have been done; slip, lapse, mistake
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At Risk Behavior
◦ Behavioral choice that increases risk where
perception of risk is lost or is mistakenly believed
to be justified
◦ May be result of cultural norms or standardization
of deviance
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Reckless Behavior
◦ Behavioral choice to consciously disregard a
substantial and unjustifiable risk
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Human Error
◦ Product of current system design
◦ Redesign the system to prevent further errors
◦ Console and learn
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At Risk Behavior
◦ Risk believed to be insignificant or justified
◦ Uncover the unsafe habits and remedy system based
reasons
◦ Decrease staff tolerance
◦ Coach and check
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Reckless Behavior
◦ Conscious disregard of unjustifiable risk
◦ Manage through disciplinary action
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Human Error
◦ You are preoccupied with work issues from the day. You are
driving home and when you see the flashing lights you look
at the speedometer and it says 80mph and the speed limit
is 60mph.
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At-Risk Behavior
◦ You are late to your son’s football game. You decide to
drive faster (80 mph in a 60 mph zone) to make it in time
for kickoff.
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Reckless Behavior
◦ You decide you are not missing kickoff for any reason and
drive 80mph, switching lanes frequently, cutting off other
drivers, all while texting your son to let him know you are
on your way.
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What happened?
What normally happens?
What does procedure require?
Why did it happen?
How were we managing it?
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Causal statements should clearly show
cause and effect relationship
Negative descriptors (ie poorly) may not be
used in causal statements
Each human error should have a preceding
cause
Each at-risk behavior should have a
preceding cause
Failure to act is only causal when there is
pre-existing duty
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Decision-making pathway
Assists with assessment of behavior as
human error, at risk or reckless
Provide suggestion for response
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Developed by The National Patient Safety
Agency in the UK
Provides a framework for objectively
assessing an individual’s actions, motives and
behavior
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Deliberate Harm Test
◦ Were the actions intended?
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Incapacity Test
◦ Was the employee impaired?
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Foresight Test
◦ Did the employee depart from agreed protocols or
safe procedures thus increasing risk?
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Substitution Test
◦ Would another comparable employee behave in the
same way in similar circumstances?
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Individual Accountability:
◦ Deliberate Harm: Discipline
◦ Incapacity: Medical Leave/EAP
◦ Foresight: Training, Supervision, Coaching
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System Accountability
◦ Substitution Test: Performance Improvement
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Unpredictable, high risk events are the norm
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Complex teams
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Environment vulnerable to medical errors
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Liability issues
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Use of High Alert Medications
Surgical Safety
Emergency Management
Interpretation of Data
Complex communication structure
High risk, low use procedures
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ISMP investigation concluded that “while the
nurse bypassed multiple safety procedures,
there were also system flaws that allowed and
even encouraged her to do so, contributing to
the fatal error.”
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Nurse did not apply ID band
Nurse did not use the hospital’s barcoding
system
Both medications were brought to the room
at the same time and before orders were
given
Nurse had worked two consecutive 8 hour
shift the day before, slept at the hospital and
came on duty the next morning
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Bar Coding system had glitches
Nurses were not adequately trained and many
often bypassed the system
No rules to prevent nurses from becoming
fatigued
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Were the actions or consequences intended?
◦ No
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Was the individual impaired?
◦ Fatigue
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Did the individual depart from policies and
procedures?
◦ Yes
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Would another individual behave in the same
way in similar circumstances?
◦ Yes
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Medical errors are devastating for the
caregiver
Investigations, Root Cause Analysis
Loss of job, income, license
Criminal charges
Emotional responses-anxiety, depression,
thoughts of suicide
NQF’s Caring for the Caregiver standard
Formal support systems and treatment for
traumatized caregivers related to errors