Archive for March, 2011|Monthly archive page

Culture eats strategy for breakfast

In human error, Patient Safety, Safety climate on March 22, 2011 at 6:02 pm

The 2011 patient safety culture report is out from the AHRQ detailing the results from the survey of patient safety culture in over 1000 hospitals with almost half a million responders. There is some good news and some very concerning news. On the bright side, teamwork and supervisor attention to patient safety received high marks with 75-80% positive responses. Very concerning however are the two lowest scores: handoffs and hospital response to error.

The positive responses to the perception of safe handoffs came in at only 45% and the perception of a non-punitive response to error weighed in at 44%. Of particular concern, as expressed many times on this blog, is the perception of 56% of respondents that response to error is punitive! This perception has not improved AT ALL since the 2007 survey when data was collected from 382 hospitals.
For the New England region only this response to error survey item elicited a positive response in a paltry, scary 38% of respondents. 62% of those working in hospitals in New England perceive that there is a punitive approach to error!
What does this mean?
A culture in which staff perceive that they will be punished for making errors, creates secrecy and a reluctance to report incidents. This can lead to great patient harm. When you blame by the bad apple theory (the error involved a bad clinician) and punish the “bad apples,” the system goes unfixed making the next patient every bit as vulnerable as the one who was harmed by the “bad apple.” Unsafe conditions and near misses go under-reported creating a significant deficit for senior leaders who are trying to improve safety and quality for their organizations. As a senior leader, even if your policy is non-punitive, if the staff believe it is punitive their behavior will be risky.

To move away from a culture of blame, I suggest going to the Just Culture community website linked on this blog or reading “Behind Human Error” (2010) by Woods, Dekker, et al.

Checking Prescriptions

In human error, Patient Safety on March 19, 2011 at 11:31 am

Another resource for patients to be sure their prescriptions were filled accurately. It enhances safety to encourage patients to check this type of site. I would also advocate for all pharmacies to include pictures of the pills along with the drug information they provide.

Pill Identifier

Coming in May

In Patient Safety on March 18, 2011 at 9:29 am


New Patient Safety book due out in May from Sidney Dekker (quoted often on this blog).

Description from the publisher CRC press:
•Presents material written with the medical practitioner audience in mind
•Includes the latest Human Factors/Ergonomics research applicable to patient safety
•Contains examples and cases on Human Factors and patient safety
•Discusses accountability and just culture
•Presents information in easy to use bulleted lists and illustrations where possible

“With coverage ranging from the influence of professional identity in medicine and problematic nature of “human error”, to the psychological and social features that characterize healthcare work, to the safety-critical aspects of interfaces and automation, this book spans the width of the human factors field and its importance for patient safety today. In addition, the book discusses topics such as accountability, just culture, and secondary victimization in the aftermath of adverse events and takes readers to the leading edge of human factors research today: complexity, systems thinking and resilience.” -CRC Press

I’ve pre-ordered this one!

More Human Factors…

In Patient Safety on March 17, 2011 at 8:48 pm

My friend received a phone message tonight asking for volunteers to do massages at the Walk for Breast Cancer (she’s an LMT). The call back phone number was difficult to hear. She first called xxx-xxx-9762 wrong number. I quickly listened to the number too and I thought it was xxx-xxx-9752. Wrong number again! I stopped, shut the lights off, and closed my eyes and said play it again. I took a deep breath and very clearly heard xxx-xxx-2222. Bingo! Right number and now my friend is helping out that day.

Why tell this story? To point out the need for quiet zones where staff can stop, take a breath and pay attention to important notes and numbers. Any inpatient areas without a quiet zone are putting their patients and staff at risk. Build one today! Look for a future post with more evidence-based information 🙂

Keep the tiny humans safe!

In Patient Safety on March 16, 2011 at 10:55 am

All patients deserve safe care but no where is it more pressing than in Peds. Check out this piece on peds safety

Here is a preview:
“I realized that it doesn’t matter how intelligent you are,” says Alleyne, who now is the patient safety/quality improvement coordinator for the cardiac center at CHOP. “You can harm a patient if you are in a system that doesn’t support safe patient care. Rather than be a critic of the system, I decided I wanted to be part of the solution. I believe that as long as people agree that there is a problem and are committed to a solution, then they will see change.”

Are you committed?


In Patient Safety on March 10, 2011 at 9:23 am

Boston Globe medication error story

Drug error with protocols and pump programming.
Human factors…human machine interaction…usability…they are all in this tragic story.

All health care providers need to DEMAND easy to use technology that reduces their cognitive load not adds to it.

Engage the patient

In Patient Safety on March 4, 2011 at 1:35 pm

I wrote in a previous post about a UK study describing a hesitancy of patients to call out professionals on safety concerns.  Check out the website: Engaging the

Here is one of their thought provoking posts about needing to consider all the side effects of a change.  The following is about asking  patients to mark their own operative sites to prevent wrong side surgeries:

“Even well-intentioned suggestions can lead to unintended consequences. We can all agree that wrong-site surgeries are needless and tragic. But ensuring that this never happens is not as simple as it would seem. In the past, patient advocates suggested patients themselves write on the body part (say a knee) to be operated on. But these marks weren’t consistent. Did ‘X’ mark the spot? Or did ‘X’ mark the knee to be avoided? What if the markings were smudged? And the marker itself can increase the risk of infection”

Read more on their site!

Underlying Patterns

In Patient Safety on March 4, 2011 at 1:26 pm

When errors or near misses occur they may look very different on the surface. Research in human factors however has determined that there are many similar patterns in errors that involve human-system interaction.

Some of the common patterns are (Carayon, 2007):

  • Trying to solve a problem with only one point of view or hypothesis
  • Missing the side effects of a plan or change
  • Hindsight bias from knowing the outcome before looking back on the contributory events
  • Front line employees have difficulty applying standards to a changing situation when they do not have a true understanding of the intent of the standards
  • Alarm overload or false alarms leading to missed or ignored warnings with machines but also conversations and interactions
  • Errors in technology devices that do not have good feedback systems.  Good feedback systems keep the operator informed as to where they are in a process or if an action has been completed.
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