Why a “Just Culture” really matters!
The identification and analysis of patient safety incidents is a quintessential component of a robust patient safety program and the culture that sustains such a program. Safety improvements arise from identification of incident-related causes and contributing factors, and front-line staff must be fully engaged in these efforts if we are to improve patient safety.
It is a common perception that physicians (the term is used to include all physicians and surgeons i.e. “doctors”) are the healthcare professionals least likely to report incidents or safety concerns or to be included in incident analysis. As key members of the front-line staff enhancing their involvement should be an important goal in the sustainment of a robust patient safety culture.
It has been said “near misses are the gold dust of patient safety.” If our profession is to become highly reliable, then learning from errors with the potential to cause harm, before they actually cause harm, is the quintessential outcome of striving for high reliability. Institutions that fail to analyze near misses are, at best, on a slower road to high reliability.
In 1848 gold was discovered at Sutter’s Mill, Coloma, California. Gold flakes were found floating in the American River, and beginning in 1849 thousands of people flocked to California in what has become known as the California Gold Rush. The prospectors became know as the “49ers.” Though most Gold Rush “49ers” did not become wealthy, the myth that the discovery of gold would lead to vast riches became entrenched in the collective experience of history. Everyone knew that the dust came from veins within the ground, the gold mines.
The fifth characteristic of high reliability organizations (HROs) is Resilience – leaders and staff responding when systems fail, collaborating to overcome challenges. For HROs, resilience means dealing with emergencies, preventing translation of these mishaps into harm for consumers and instituting corrective actions. How does your hospital measure up?
Case Study: A 2-year old with rhabdomyosarcoma is receiving actinomycin-D and doxorubicin chemotherapy. The child’s liver function studies, though abnormal, were not reviewed prior to ordering doxorubicin. She receives a dose that is three times normal, develops bone marrow suppression and fulminant sepsis. She nearly dies. Her subsequent therapies are delayed, and her prognosis worsened.
The National Advisory Group on the Safety of Patients in England was commissioned to formulate recommendations for improvements in safety arising from problems identified in the Mid Staffordshire Public Inquiry¹ and has just released its report². This report was written by thoughtful people who have long admired and/or worked in the NHS and who recognize the high quality of care that has been, and can continue to be, provided to the citizens of England.
The report identified compelling challenges confronting NHS England, most notably a less than perfect patient centric focus and a bureaucracy so encumbered, such that responsibilities were dispersed to the point that it was unclear who was accountable, and for what. “When responsibility is diffused, it is not clearly owned: with too many in charge, no-one is.”
The fourth characteristic of high reliability organizations is Deference to Expertise – leaders listening to, and seeking advice from, frontline staff who know how processes really work and where risks arise. If you want to understand how the machine works you should ask the nuts and bolts and gears because without them the larger bits and pieces can’t work efficiently and will predictably fail…, repeatedly!
Standard wire diagrams, with boxes and connecting wires, are often used to portray the relationships of authority and responsibility in hospitals. Typically missing from these diagrams are the people who sit in the White Spaces beneath the labelled boxes or adjacent to the wires, the front line people who are continually crossing and communicating, those who provide the most pragmatic aspects of work in the hospital; and the people who touch the patients and hold the hands of family members.
The third defining characteristic of high reliability organisations is a tenacious single mindedness when predicting and eliminating harm. A presumption that things will go wrong creates a focus that values investigations of near misses and incidents as seamless links to disaster prevention and response planning.
Healthcare today is plagued by pernicious complacency, a malevolent and commonly unrecognized force, that affects our ability to prevent incidents and to react appropriately and expeditiously when they do occur. Near misses happen every day in the complex environment in which healthcare is provided and yet these are nearly always overlooked, or simply corrected but not shared for the sake of learning. There are certainly “sentinel near-misses” that are recognized, analysed, recorded and shared with the broader community. However, more often than not near misses are not recognized as the learning opportunities they truly are. We undervalue near misses as sources of learning.
I am interested in discussing the value of classifying patient safety events within graduated severity levels in contrast to using harm/no harm classification. At the current time, we are using the following severity classifications: hazard, close call, minimal harm, moderate harm, severe harm and death. While the identification of greater harm events may have some value, it detracts from the application of focus to no harm or lesser harm events. It is also generally difficult to identify if greater harm events are the result of medical intervention or from the disease process itself.
The second characteristic that defines high reliability organizations is the Reluctance to Simplify – the avoidance of simplistic explanations for risks or failures and a commitment to delve deeply to understand vulnerabilities, especially when these involve human factors.
Once again I refer to Professor Reason’s Swiss cheese model for accident causality. Investigations of causality require us to think beyond the holes in the first or second slices of cheese and to meander through the substance of the Emmental, to probe for the weak spots, the tiny holes or the “about to become” holes.
I was asked to review a root cause analysis (RCA) involving the death of a patient following a routine cholecystectomy (removal of the gallbladder). The patient was obese, had a longstanding history of psychological problems and hypochondriacal complaints.
The first characteristic that defines high reliability organizations is Sensitivity to Operations, a constant awareness by leaders and staff to risks and a mindfulness of the complexities of systems; essentially an attack on pernicious complacency!
The tremendous advances in healthcare over the past 50 years have been accompanied by substantial increases in the complexities of care. The great successes must be framed within the context of unsustainable growth in healthcare expenditures, overutilization without consistently improved outcomes, and an enormous awareness of the unintended harm that is done everyday. In the USA over 400 patients die daily as a result of healthcare. Success is in the eyes of the beholder.
A root cause is the lack of consistent Sensitivity to Operations. Those of us working in healthcare have become dangerously complacent about our environment and our own behaviour. We don’t see the risks, and even when we do see the risks we don’t recognize them for what they are; and we often don’t act to eliminate them. We must collectively appreciate, that though our intentions may be benevolent, our actions or inactions may result in harm. We do not get up in the morning intending to harm anyone but predictably, with considerable certainty, some of us will.
Professor James Reason’s Swiss cheese metaphor for accident causation is a highly regarded model of how multiple aspects often align in causality and how prevention/avoidance barriers exist in most circumstances. I have learned this lesson well…
A 10-month-old child was admitted on the weekend for evaluation of a renal mass, likely a Wilms’ tumour. The institutional protocol required the oncology registrar to administer Actinomycin-D intravenously as soon as the renal vein had been clamped. I wrote the orders correctly and legibly using our standard double-check process.
Unfortunately, in addition to covering the inpatient oncology service I had weekend obligations for the outpatient clinic and the bone marrow transplant unit, located in two different, though adjacent, hospitals.