Archive for the ‘Patient Safety’ Category

Way to take the Lead Brigham and Womens!

In Patient Safety on March 3, 2016 at 5:44 pm

SAfety MAtters


From their website

Brigham and Women’s Hospital is dedicated to providing the safest, highest quality care to every patient we serve. Part of our commitment to safety includes telling our stories about mistakes we have made, what we have learned from them and the improvements we are making as a result.

Our goal is simple: By telling these stories, we hope to show everyone that, while improving care is not easy, we are absolutely committed to transparency, to learning from our mistakes and to continuous improvement.

Each story that we share is accompanied by a Just Culture corner. To achieve our goal of learning from mistakes, we know that staff must feel safe and supported in speaking up about making a mistake. Just Culture ensures that we treat staff fairly, that we support each other and take the opportunity to provide education and fix our systems when a mistake occurs.


Let’s make their blog super popular!!


QI tools from across the pond

In Patient Safety on November 8, 2015 at 2:30 pm

Great list of simple tools to use to make improvements,com_quality_and_service_improvement_tools/Itemid,5015.html

Culture transformation Thursday : power and deviance

In Patient Safety on October 21, 2015 at 12:11 pm

There are some interesting leadership behaviors that can occur in an unsupportive workplace environment. When a leader gets frustrated with lack of progress on an initiative or overall group day to day performance they can attempt to regain control by exerting power (kind of like parenting?  “because I am your mother thats why!”).

There is a theory of how employees repond to this (Sims, 2010):

  1. Leader Display of Power
  2. Employee becomes frustrated… might product feelings of threats to autonomy/social identity and feelings of injustice
  3. Two options:

1) Employee accepts this

2) Employee rejects the display of power by:

  1. a) displaying exit behaviors which can be physical or emotional (eg. leave the group or physically stay but become disengaged).
  2. b) using the employee voice: which is productive if its internal and listened to and used to find a better solution or non-productive if the voice is ignored or used outside of the group to bad mouth the leader or the group in general

A group who perceives this cycle to be repeating over and over(even if its not true), eventually may adopt a deviant culture where negative organizational behaviors become the norm.  When this happens even internally motivated, self-regulated individuals can conform to socialization.  In general, people need to feel a sense of equity: that the reward they get from work matches the effort they put out (Henle, 2005). Rewards are more than just money. They can be respect, acknowledgement, educational opportunities, a good schedule, gratitude from patients/customers, etc…In times of budget restriction, the rewards for employees are usually reduced and the work demands are increased, thus creating a potentially harmful mismatch.

One of the mediators of workplace deviance is interactional justice.  In a leader this would mean treating all with sensitivity, dignity and respect and giving adequate explanations for decisions made AND taking ownership for decisions made. Staff experience more frustration if they feel their leader does not agree with an organizational decision but is powerless to fix it. Senior leadership has an obligation to give their middle managers adequate explanations and a list of talking points to help disseminate the information. If the decision does not have a valid explanation maybe it is not the right decision!  There are many psychological biases inherent in leadership decision-making that can compromise effective operational strategy.

Another mediator of workplace deviance is to have leader and employee goals that match.  It is important to understand employee workplace goals. A good leader will help the employee discover how their goals can align with the organizational goals or in a case where there might be a poor fit and the goals do not align, coach the employee to seek an alternate environment.

Those employees whose goals do align can be used to create positive deviance within the group.  Involve them in projects that fit with their goals. Eventually the norms of the group will change and become more aligned with the organizational goals creating benefit for the organization and engagement in the employees.

Unintended Consequences

In Patient Safety on April 28, 2015 at 7:37 am

I live in an 18 floor building and ride the elevator often. When there are older gentlemen riding with me they usually step aside to let me out first.  While this appears chivalrous it actually lens me to be the one to open the garage door which is usually fairly difficult due to the wind pattern.Sometimes’s it hurts my arm.
When I realized this, I began to motion to let the men out first. Most often I am greeted by a smile and a slight bow “oh no ladies first”. I have been hesitant to say anything as the men are often quite pleased with their chivalry.

How often in health care are we pleased with ourselves for doing the right thing or following best practices when in fact we might have made things more difficult or even harmful for a patient? If they think we are nice and mean well will they even tell us?

Watch for unintended consequences.If you don’t look or ask you won’t find them and you might just be doing more harm than good


In Patient Safety on October 12, 2014 at 9:04 am

Ebola has the potential to be a real chink in the armor for patient safety. Here are some of my thoughts

1. anyone currently thinking of becoming a doctor or nurse is totally rethinking that decision right now. I am afraid we will end up with the worst HCW shortage the US has ever seen
2. That said, hospitals better start working on having an ageless workplace so their current staff can continue working past retirement age
3. IF current PPE has major limitations, working conditions are about to deteriorate. IT is very difficult to care for a patient in full hazardous material garb
4. Current guidelines for ebola recommend limiting the number of people entering an ebola patient’s room. Where does this leave all of our double check processes?
5. Taking off PPE is very challenging. Breaching infection control protocol during this is actually easy to do. We are going to need HCW monitored during the removal process. No institution has the funds to introduce a flood of new workers into the system. If so they will likely try to do this with non-professionals who might not have the same level of understanding of infection control no matter how much training they receive.

One bright spot: current health care environments are focused on financials such as cutting workers, encouraging multitasking, prioritizing efficiency over safety..

Ebola is chance to slow things down, go back to prioritizing safety..allow time for staff to think..and support each other.. make adjustments to facilitate an ageless workplace-its good for your older employees but also for all. And many times whats safe for healthcare workers is also safe for patients and vice versa

Often times when a person gets an illness like cancer, they call it their wake up call to stop spinning and start slowing down and paying attention to life and quality. Ebola is the healthcare systems’ wake up call..

Neuroscience Saturday: BJ Fogg and Starter Steps

In Behavior change, Patient Safety, Resiliency, Safety climate, usability, user experience on July 19, 2014 at 8:35 am

Anyone who knows me knows I love BJ Fogg’s behavior models. He is a design psychologist who runs a persuation lab out at Stanford. His latest behavior change model is based on his research about lasting change which basically falls down to: making things easy to do and changing the environment.
His latest little flip book sums up his findings to date.
Lots of lessons for us in healthcare and these are my take aways:
*we tend to love dramatic change initiatives: secret: they usually dont work
*Starter steps or baby steps arent glamorous and flashy but they work
*We clearly need to reward change and not the flashing marketing campaigns when it comes to safety (how many hours have you spent on catchy acronyms….did it make a difference??)
*BJ desribes certain things to look for that can warn you that you are designing for epiphany instead of change secret: hoping staff epiphanies will lead to behavior change doesnt usually work

If you care about patient safety AT ALL please read BJ’s latest little flipbook.. I have never read so much great info in one place

This about sums up all that healthcare should be

In Patient Safety on May 31, 2014 at 3:33 pm

This about sums up all that healthcare should be

Patient Safety where it belongs

HXD 2014

Story telling to change safety culture

In Behavior change, BEST.ARTICLE.EVER., Patient Safety, Safety climate on May 26, 2014 at 5:04 pm

While this study is about the workplace and not patient safety in particular, it shows the importance of story telling on culture.
Workplace culture influences patient safety.

The researchers identified several forms and functions of these stories:

To control behavior: These forms of stories serve as lessons, and indoctrination to the behaviors that are either encouraged or discouraged by the moral. Themes of punishment or reward are common.
Oppositional stories: These stories provide an outlet for expressing frustration with the company. Researchers suggested that even these types of stories can be used strategically, if key leaders in the organization are aware of them.
Differentiation/integration: This type of story serves to answer the question, “Who are we as a group?” These stories establish the unique identity of the company, and make a distinction between the organization and its competitors. These tales shape impressions of the organization, and the employees’ place within it.
Preparation for the future and change: These stories can be used to provide stability and a road map during times of difficulty or change by setting examples for solving problems.

Read more

Chocolates and patient safety

In High Reliability Orgs, Normal Accident Theory, Patient Safety, Resiliency on September 22, 2013 at 3:17 pm

From Rosemary Gibson:

How Overtreatment and High Volume Health Care is Making Patient Safety a More Distant Reality by Rosemary Gibson

“This past week at the National Health Care Quality Colloquium I showed the classic “I Love Lucy” chocolate factory video during a presentation. The laughter was audible and the point was made: when the pace of work speeds up, work-arounds and cutting corners are inevitable. Employees tell the boss everything is fine –when its not.

In a health care system riddled with defects where doctors and nurses are required by health care executives to work at a faster pace, the number of adverse events — and patients harmed — will increase. High volume health care and productivity targets are a toxic mix. … Read and’s funny but not…
The Chocolate scene on you tube

Forbes takes on the FDA

In Patient Safety on July 2, 2013 at 7:31 pm

Recall of Wellbutrin XL (from oct 2012)

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