Archive for the ‘culture’ Category

Lessons from a Cat

In culture, Human Factors, Just Culture on June 7, 2015 at 3:52 pm
Good kitty or bad kitty?

Good kitty or bad kitty?

After three years of amazing litter box use (she even went in the litter box to cough up hairballs), my cat Muffin looked me in the eye and pooped right on a rug outside of her litter box. At first I thought she was sick. But then she played and acted normal for the rest of the evening. When I woke up in the morning, I noticed she had peed all over the rug. This was such unusual behavior.

I searched the internet and found many theories of cat behavior. Maybe she didnt like the new litter, maybe her box was too dirty, maybe she was upset. I decided to buy her a totally new litter box and went back to her fav kitty litter. I bought a slightly smaller box than she was used to because the other one had to squeeze into the fake furniture housing that encased it and I didn’t clean it as thoroughly as I should because it was challenging to get in and out.

It seemed to work! Muffin was doing her business back in the box. After a week or so when I took the box out to clean it, I noticed urine all underneath it. UGH! she was peeing outside the box. Maybe this was behavioral after-all. Time to google cat therapists.

Let’s look at this from a just culture lens.

Initially I thought Muffin’s defiant voiding outside of her box was a protest…malicious behavior. Then after searching cat behavior, i thought maybe she was just being reckless. Then one day after cleaning all the urine under the litter box, i noticed that the side of the pan where she usually pees was pretty short. I flipped the pan around and put the taller side in that spot. Like magic problem solved! Muffin never meant to be malicious or reckless nor was she making a mistake! With a little redesign of her environment…problem solved! She just needed new better designed equipment.

Do we support help our healthcare workers in redesigning their environment for safety  or do we just accuse them of making errors and being reckless?

TBT: Ahrq 2014 safety culture survey.

In adverse events, culture on April 3, 2014 at 10:03 am

I called this throw back thursday because it doesn’t seem we have made much progress over the years. This is concerning. And probably relates to HAI and other undesirable outcomes. Maybe it’s just a fantasy that if we fix these the other things will fall into place easier? see my same post in 2012!

Areas With Potential for Improvement for Most Hospitals

The three areas that showed potential for improvement, or with the lowest average percent positive responses, were:

Nonpunitive Response to Error (44 percent positive response)—the extent to which staff feel that their mistakes and event reports are not held against them and that mistakes are not kept in their personnel file.
Handoffs and Transitions (47 percent positive response)—the extent to which important patient care information is transferred across hospital units and during shift changes.
Staffing (55 percent positive response)—the extent to which there are enough staff to handle the workload and work hours are appropriate to provide the best care for patients.

A reminder to Listen to the children

In culture on April 23, 2013 at 10:13 am


Luck of the Irish or workflow?

In Behavior change, culture, user experience on March 17, 2013 at 9:27 am

According to the Office of the National Coordinator (ONC), 30% of all Health IT implementations fail. What causes failure? A workforce that doesnt want to change? Poor technology? Luck?
It’s unlikely to be any of these things. It is usually the inattention to workflow and culture that leads to failure of Health IT initiatives designed to improve patient safety.
What do hosptial IT execs know about the culture of their institutions? Probably not much. Aminstrators in general have different opinions of safety culture than front line staff (the latter see less safety). How often do we do post IT implementation and periodic surveys to see if workflow is indeed more “flowing” than bottlenecked? My guess is not very often or we would see these survey results at the top of every Health IT companies webpage. Most products now are only rated by IT execs through a propriatary report. We need a marketplace website for all thse like Amazon where end users can rate and evaluate the products!!

Read the chapter from Patient Safety and Quality for Nurses from the NIH
about workflow.
Cain C, Haque S. Organizational Workflow and Its Impact on Work Quality. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 31. Available from:

Holy toledo! A lost kidney?

In culture, human error on September 26, 2012 at 7:58 pm

The story of a kidney thrown out by accident during surgery to remove said kidney for the donor to donate to her sister!

Horrible incident… the nurses were fired…wrong solution.  blame and shame will not fix a major problem like this!

This seems like a total system/ culture issue as no one in the room who knew the kidney was in the items that were thrown out spoke up!

McKayla is not impressed…goes viral

In culture on August 12, 2012 at 9:18 am

Olympic medalist McKayla Maroney has become a viral sensation after her expression of disappointment spawned McKayla is not impressed photos.

Here is my Patient safety themed meme:

Transparent Health

In adverse events, culture, Human Factors on June 23, 2012 at 3:20 pm

Excellent patient safety resources from the folks at University of Illinois at Chicago.
Their blog:
There is a great post about collusion. If you see safety issues in healthcare and do not report, you should feel culpability.

Their educational site

If you are a healthcareworker, spend the $75 and Watch the Lewis Blackman story. You will be motivated to become a patient safety advocate. Lewis who was a totally healthy 15 year old, went in for elective surgery and died from a GI bleed related to toradol post op. The sequence of events happen everyday…there is nothing earthshattering until..there is.
Some key topics in this film: premature closure, confirmation bias, rapid response teams, chain of command, identification of rank of healthcare workers…listening to parents concerns..
Click to purchase pay-per-view From tears to transparency

Summary of Healthcare Design Conference

In culture, Patient empowerment, Patient Safety on April 11, 2012 at 11:13 am

Technology is so important for safety. More clinicians need to be at these conferences as the disruption of healthcare is evident in these presentations.  We need to move forward.

Patient empowerment is another theme at this yearly conference.  Patient empowerment is key to safety.


Cheese and safety; cookies and safety!

In Behavior change, culture, Force function on March 17, 2012 at 7:52 am

On this blog we have seen the analogy of swiss cheese to safety in the form of James Reason’s swiss cheese model of failure.  Now what could cookies, as yummy as they are, possibly have to do with safety?

Yesterday, I walked up to the city marketplace after work to get a snack:  Chipyard cookies were calling my name. As I approached the stand, I recalled a story from a colleague who was fired from this company in college. It seems after baking the cookies, the staff were required to take the hot trays from the oven and load them onto to a backing rack. The procedure would be to yell “hot tray” and then slide the tray onto the rack to cool. Several times, my colleague yelled “hot tray” and as she was placing the tray into the rack she would use a bit too much force and the tray would slide out the back of the rack through an open window panel! The “hot tray” of cookies would drop out onto the pavement behind the cookie stand rendering them unsellable.

She was shown the “safety” procedure several times yet somehow the cookies kept ending up on the pavement.  Thinking she hired a bad apple, the manager fired my colleague who is now an incredible nurse who saves kids’ lives…bad apple indeed.

When I walked up to the cookie stand last evening I noticed something amazing. They had built a small wall right behind the cooling rack!  I asked the girl at the counter “Hey does anyone ever ruin the hot tray of cookies by knocking them through the rack?” She looked at me increduously! This new generation of workers could not even conceive of making an error of this type.  This is forced function at its best and illustrates the effectiveness of this type of intervention over education and prompts to do better to eliminate safety hazards.

Do we have similar situations in healthcare? Are we telling staff over and over “Don’t make this mistake” “watch what you are doing!” “be more careful”  or are we building barriers to unsafe actions and behaviors that will create and sustain safety for our patients?

I can think of one success in particular.  Seasoned nurses will talk about the old days when they mixed chemotherapy in the kitchen on the inpatient units.  New nurses will listen with horror as they only know chemotherapy that comes in specially prepared and labelled containers from the pharmacy.

Real safety comes from designing safe systems and critiquing everyday provider choices and behaviors (Just Culture Community, 2008).  

Look around your environment. What safety hazards/behaviors could you render obsolete for the next generation?

Celebrate patient safety!

In Behavior change, culture, Patient Safety, Safety climate on March 4, 2012 at 4:57 am

Happy patient safety awareness week! it’s time to make one commitment to safety no matter how small. use bj fogg’s 3 tiny habits method to make it stick!

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