ce activity information & accreditation · 2016. 7. 19. · • i am someone’s mother, wife,...

Just Culture: A Necessity for Safety and Living a Better LifePharMEDium Lunch and Learn Series

ProCE, Inc.www.ProCE.com 1

Just Culture: A Necessity for Safety and Living a Better LifeJanuary 9, 2015

LUNCH AND LEARN

Featured Speaker: Natasha Nicol, PharmD, FASHP

Director, Consulting and Patient SafetyCardinal Health Innovative Delivery Solutions

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CE Activity Information & Accreditation

ProCE, Inc. (Pharmacist and Tech CE)

1.0 contact hour

Funding: This activity is self‐funded through

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g y gPharMEDium.

It is the policy of ProCE, Inc. to ensure balance, independence, objectivity and scientific rigor in all of its continuing education activities. Faculty must disclose to participants the existence of any significant financial interest or any other relationship with the manufacturer of any commercial product(s) discussed in an educational presentation. Dr. Nicol has no relevant commercial and/or financial relationships to disclose.



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Submission of an online self assessment and evaluation is the only way to obtain CE credit for this webinar

Go to www.ProCE.com/PharMEDiumRx

Print your CE Statement online

Live CE Deadline: February 6, 2015

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– CE information automatically uploaded to NABP/CPE Monitor within 1 to 2 weeks of the completion of the self‐assessment and evaluation

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Code will be provided at the end of today’s activityEvent Code not needed for On‐Demand

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Submit your questions to your site manager.

Questions will be answered at the end of the presentation.

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Your question. . . ?



Resources

Visit www.ProCE.com/PharMEDiumRx to access:

Handouts– Handouts

– Activity information

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– Links to receive CE credit

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Just Culture:JustCulture:ANecessityforSafetyandLivingaBetterLifeNatasha Nicol, Pharm D, FASHPDirector, Consulting and Patient SafetyCardinal HealthJanuary 9, 2015

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Disclosure

• I do not have a vested interest in or affiliation with any corporate organization offering financial support or grantcorporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias my presentation.

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AboutMe

• I am someone’s mother, wife, daughter, granddaughter sister aunt cousin and niecegranddaughter, sister, aunt, cousin and niece.

• I am married to a physician and have a sister and niece who are nurses.

• I am educated.

• I am a good pharmacist.

• I have a story to tell you.

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“Medicine used to be simple, ineffective and relatively safeineffective, and relatively safe. Now it is complex, effective, and potentially dangerous.”

Si C il Ch l— Sir Cyril Chantler

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Boeing747• 450 would have to crash every year to equal medical deaths

• That’s more than ONE A DAY!That s more than ONE A DAY!

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HospitalSurveyonPatientSafetyCulture

• Only 44% of employees are confident they wouldn’t be punished if they reported an errorwouldn t be punished if they reported an error

Agency for Healthcare Research and Quality. Hospital Survey on Patient Safety Culture.11

Anyonerecognizethesetwins?

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RichardSmith– 2010,Florida

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15‐year‐oldLewisBlackman–2000,MUSC

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17‐year‐oldJesica – 2003,Duke

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EmilyJerry– 2006,Ohio

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Wikipediasays:

• Common estimates for sustained attention to asustained attention to a freely chosen task range from about 5 minutes for a 2‐year‐old child, to a maximum of around 20 minutes in older children and adults.

http://en.wikipedia.org/wiki/Attention_span. Accessed January 2, 2015.17

RhodeIsland:Wrong‐SideBrainSurgery(x3)

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58‐year‐oldJeanetteMcAllister–1997,Florida

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Isthehealthcareindustryalone?

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CommuterTrainWreck–2008,California

25 dead

http://www.msnbc.msn.com/id/34978572/ns/us_news‐life/t/ntsb‐blames‐texting‐deadly‐calif‐rail‐crash/. Accessed January 2, 2015.

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Zipline Accident:Patricia–Maui,Hawaii2014

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I‐35WMinneapolisBridgeCollapse– 2007

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NumberofUSBridgesinDangerofCollapse

>7,700

Source: 2013 Federal analysis

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MasseyMineExplosion– 2010

29 dead29 dead

http://www.topicboss.com/topic/massey‐coal‐mine/http://www.wsws.org/articles/2010/apr2010/mine‐a12.shtml 25

Arizona– 2014

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January21,2011

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WhatWeAllHaveinCommon

• Fallible humans and human behaviors

I f t t• Imperfect systems

• Potential for faulty equipment

• A set of values (individual and/or corporate)

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GreatSystemsEverywhere(IncludingAirportBathrooms!)

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...AndSomeNotSoGreat

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CreatingaJustCulture:WhereDoYouStart?

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JustCultureDefinition

W k h h d d fWorkers trust each other, are rewarded for providing safety information, and are clear about their responsibilities regarding safe

behavioral choices.

There is a shared accountability.

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TypesofBehaviorInvolvedinErrors• Human error: an inadvertent action; inadvertently doing other than what should haveinadvertently doing other than what should have been done; slip, lapse, or mistake

• At‐risk behavior: a behavioral choice that increases risk where risk is not recognized, or is mistakenly believed to be justified

• Reckless behavior: a behavioral choice to• Reckless behavior: a behavioral choice to consciously disregard a substantial and unjustifiable risk

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Consoling– HumanError

• A conversation to learn

H l b f ti th l• Help by comforting the employee

• Manager also investigates the system and makes changes as appropriate

The employee made the mistake, not the choice

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RepetitiveHumanError:Counseling

T k tiTake action:

• Let the employee know that performance is unacceptable

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RiskyBusiness

• In states that have enacted laws against texting while driving has the accident rate gone up or down?driving, has the accident rate gone up or down?

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It’sAllAboutPerception ofRisk

http://www.dailymail.co.uk/news/article‐2127859/Like‐father‐like‐son‐Baby‐Bob‐Irwin‐feeds‐alligators‐late‐daddy‐Steve‐s‐animal‐park‐aged‐just‐EIGHT.html 37

CoachingAt‐RiskBehavior

• Create a learning opportunity:

U d t d th i i t f i• Understand their point of view

• Describe the at‐risk behavior

• Explain how this behavior isn’t aligned with our values

• Create an action plan

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DrinkingandDriving–ClearlyRecklessReckless Behavior is a conscious disregard of a

substantial and unjustifiable risk

>13,000 deaths per year39

ManagingRecklessBehavior

• Disciplinary action

P i h t• Punishment

• Punitive action

Yes I said “punitive”!Yes, I said punitive !

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WeNeedaLearningCulture

• Learn about errors and the behavioral choices behind thembehind them

• Learn where the system is weak

• Learn why people drift

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InvestigationofEvents

• Do not regard an event as “something to be fixed”fixed

• An event is an opportunity to understand risks• System• Behavioral

• Keep in mind, the system is sometimes comprised of:comprised of:

• Faulty equipment

• Imperfect processes

• Fallible humans

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QuestionstoAsk

• What happened?

Wh t ll h ?• What normally happens?

• What does procedure require?

• Why did it happen?

• How were you managing it?

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Scenario

• The NICU nurse goes to the automated cabinet to retrieve heparin 1,000 units/mL for her patient

• Without looking into the bin, she grabs a vial• She draws up the medication and administers it to the patient

• Unbeknownst to her, the pharmacy technician had refilled the bin incorrectly with 10,000 units/mLheparin

• Choose your own adventure:A. The child was not harmedB. The child suffered severe bleeding and his

survival is in question

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AvoidSeverityBias

• Harm vs. no harm

H d h dl th it ti ?• How do you handle the situation?

• “No harm, no foul” doesn’t work in a Just Culture

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DeterminetheCauses

Probable Cause Direct Cause

(Cause of the behavioral choice) (Behavioral choice) (Human error)

RN drew up wrong med and administered it

RN always got right heparin from this pocket; felt no need to read label

RN did not read the label on drug

Patient given wrong dose of heparin

(Cause of the human error) (Outcome)

Pharmacy stocked the drug incorrectly

Why?

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JustCultureAlgorithm(Abbrev.)

Step 1 Step 2 Step 3

Was the error/ event intentional?

Substance abuse involved?

Did the employee knowingly violate a policy/ procedure?

No No

Yes

Was the harmintentional?

No

Yes

Yes Yes

No Could the same event occur with another person?

www.justculture.org

• Contact HR, Risk Management• May need to contact authorities

• Was the person properly trained?• Was the policy/procedure clear?• Was the policy/procedure correct?• Does this person have a record?

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FindtheCauses

It is the causes of the error that give us the data we need to begin to

work on and build risk‐reduction strategies

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ce activity information & accreditation · 2016. 7. 19. · • i am someone’s mother, wife,...

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