ToErrIsHuman

PatientSafetyYourSafetyOurSafety

CultureofSafety

80%ofmedicalerrorsaresystemderived GoodpeoplesimplyworkingharderwillnotbesufficienttoovercomethehighcomplexityinherentinEMS.

Errorswilloccur Thekeyistodesignsystemssothatharmdoesnotreachthepatient.

Reasons"SwissCheese"Model

Reason,James.Humanerror:modelsandmanagement.BritishMedicalJournal2000;320:768770.

CultureofSafety

Thebenefitofthisapproachtomanagingbehavioristhattheprocessisupfrontandtransparenttothestaff,whichhelpstoachievetrust.

Risksbecomeidentified,recklessbehaviorisnttolerated,andultimatelytheorganizationissafer.

Inpracticalterms,todayyouare3xmorelikelytobeinvolvedinaMVCand1,000xmorelikelytobeinvolvedinamedicalerrorthaninanaviationrelatedincident,dueinparttothisculturalshift.

AnIntroductiontoJustCulture

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

SafeCulture Thefirstandpossiblymostimportantstepinpromotingasafe

cultureistheestablishmentofjustice. JustCulture Asystemofsharedaccountability Theorganizationisresponsibleforsafesystemandprocessdesign Andemployeesareresponsibleforsafechoicesandbehaviors

Thisshiftsanorganizationawayfromablameculture. Why? Becausetodesignsafety,theorganizationneedsfeedbackfrom

users(employees). Togivefeedback,employeesneedtrust. Anorganizationcanestablishthistrustthroughaconsistentandfair

approachtomanagingemployeebehaviors.

EstablishmentofaJustCulture

EstablishmentofaJustCulture OutcomeEngineeringofPlato,Texasdefinesthesethree

behaviorsasfollows: HumanError:

Aninadvertentaction;inadvertentlydoingotherthatwhatshouldhavebeendone;slip,lapse,mistake.

Productofcurrentsystemdesignandbehavioralchoices AtRiskBehavior:

Abehavioralchoicethatincreasesriskwhereriskisnotrecognized,orismistakenlybelievedtobejustified.

Achoice,riskbelievedinsignificantorjustified RecklessBehavior:

Abehavioralchoicetoconsciouslydisregardasubstantialandunjustifiablerisk.

EstablishmentofaJustCulture

HumanError: Aninadvertentaction;inadvertentlydoingotherthatwhatshouldhavebeendone;slip,lapse,mistake.

Productofcurrentsystemdesignandbehavioralchoices

Managethroughchangesin: Processes&Procedures Design Training

Console

EstablishmentofaJustCulture

AtRiskBehavior: A behavioralchoicethatincreasesriskwhereriskisnotrecognized,orismistakenlybelievedtobejustified.

Achoice,riskbelievedinsignificantorjustified Managethrough:

Removingincentivesforatriskbehaviors Creatingincentivesforhealthybehaviors Increasingsituationalawareness

Coach

RequiresAChangeinCulture

Treateverydrugadministrationasifitswrongandwillkillthepatient

JohnNance

SuggestedMeds: Narcotics,toincludeKetamine Epi1:1,000vsEpi1:10,000 MagSulfate AnyPediatricDose Rarelyusedmedications[Diltiazem] AllCCPmedications

EstablishmentofaJustCulture

RecklessBehavior: Abehavioralchoicetoconsciouslydisregardasubstantialandunjustifiablerisk

Managethrough: Remedialaction Punitiveaction

Discipline

AccountabilityforOurBehaviorsHumanError AtRiskBehavior RecklessBehavior

Inadvertentaction:slip,lapse,mistake

Achoice:risknotrecognizedorbelievedjustified

Consciousdisregardofunreasonablerisk

Managethroughchangesin: Processes Procedures Training Design Environment

Managethrough: Removeincentives

foratriskbehaviors

Createincentivesforhealthybehaviors

Increasesituationalawareness

Managethrough: Remedialaction Punitiveaction

Console Coach Discipline/Sanction

Whatdoyousee?

JustCulture NotBlameAlsonotcarefree

Ajustculturerecognizesthatindividualpractitionersshouldnotbeheldaccountableforsystemfailingsoverwhichtheyhavenocontrol.

Ajustculturealsorecognizesmanyerrorsrepresentpredictableinteractionsbetweenhumanoperatorsandthesystemsinwhichtheywork;andrecognizesthatcompetentprofessionalsmakemistakes.

Alsoacknowledgesthatevencompetentprofessionalswilldevelopunhealthynorms(shortcuts,routineruleviolations).

Ajustculturehaszerotolerance forrecklessbehavior.

WrongMedicationDoseHumanError AtRiskBehavior RecklessBehavior

Inadvertentaction:slip,lapse,mistake

Achoice:risknotrecognizedorbelievedjustified

Consciousdisregardofunreasonablerisk

Idrewup4mgandgaveitIV,thenimmediatelyrealizedthatitshouldhavebeen0.4mg

Iwouldhavedoublecheckedwithmypartner,butshewasoutgettingsupplies,andIwantedtogetthepatienttreated

Ihaveeverythingmemorizedanddontrelyoncheatsheetsandcanttrustanothermedic

Console Coach Discipline/Sanction

WrongMedicationDoseHumanError AtRiskBehavior RecklessBehavior

Inadvertentaction:slip,lapse,mistake

Achoice:risknotrecognizedorbelievedjustified

Consciousdisregardofunreasonablerisk

Idrewup4mgandgaveitIV,thenimmediatelyrealizedthatitshouldhavebeen0.4mg

Iwouldhavedoublecheckedwithmypartner,butshewasoutgettingsupplies,andIwantedtogetthepatienttreated

Ihaveeverythingmemorizedanddontrelyoncheatsheetsandcanttrustanothermedic

Console Coach Discipline/Sanction

WrongMedicationDoseHumanError AtRiskBehavior RecklessBehavior

Inadvertentaction:slip,lapse,mistake

Achoice:risknotrecognizedorbelievedjustified

Consciousdisregardofunreasonablerisk

Idrewup4mgandgaveitIV,thenimmediatelyrealizedthatitshouldhavebeen0.4mg

Iwouldhavedoublecheckedwithmypartner,butshewasoutgettingsupplies,andIwantedtogetthepatienttreated

Ihaveeverythingmemorizedanddontrelyoncheatsheetsandcanttrustanothermedic

Console Coach Discipline/Sanction

RSI:ParalysisWithoutSedationHumanError AtRiskBehavior RecklessBehavior

Inadvertentaction:slip,lapse,mistake

Achoice:risknotrecognizedorbelievedjustified

Consciousdisregardofunreasonablerisk

3amcall,verybusynight,Iwastired

Patienthadaheadinjuryandwasunconscioussodidntneedsedation

PatientisdementedandwontrememberanywayorIveneverhadapatientcomplain

Console Coach Discipline/Sanction

RSI:ParalysisWithoutSedationHumanError AtRiskBehavior RecklessBehavior

Inadvertentaction:slip,lapse,mistake

Achoice:risknotrecognizedorbelievedjustified

Consciousdisregardofunreasonablerisk

3amcall,verybusynight,Iwastired

Patienthadaheadinjuryandwasunconscioussodidntneedsedation

PatientisdementedandwontrememberanywayorIveneverhadapatientcomplain

Console Coach Discipline/Sanction

RSI:ParalysisWithoutSedationHumanError AtRiskBehavior RecklessBehavior

Inadvertentaction:slip,lapse,mistake

Achoice:risknotrecognizedorbelievedjustified

Consciousdisregardofunreasonablerisk

3amcall,verybusynight,Iwastired

Patienthadaheadinjuryandwasunconscioussodidntneedsedation

PatientisdementedandwontrememberanywayorIveneverhadapatientcomplain

Console Coach Discipline/Sanction

AccountabilityforOurBehaviorsHumanError AtRiskBehavior RecklessBehavior

Inadvertentaction:slip,lapse,mistake

Achoice:risknotrecognizedorbelievedjustified

Consciousdisregardofunreasonablerisk

Managethroughchangesin: Processes Procedures Training Design Environment

Managethrough: Removeincentives

foratriskbehaviors

Createincentivesforhealthybehaviors

Increasesituationalawareness

Managethrough: Remedialaction Punitiveaction

Console Coach Discipline/Sanction

AssumeGoodIntent

JustCulture NotBlame.Alsonotcarefree.Ajustculturehaszerotolerance forrecklessbehavior.