Archive for the ‘Safety climate’ Category

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

Capitol Hill and Patient Harm

In safety, Safety climate on July 19, 2014 at 8:26 am


WASHINGTON, D.C. — The health care community is not doing enough to track and prevent widespread harm to patients, and preventable deaths and injuries in hospitals and other settings will continue unless Congress takes action, medical experts said today on Capitol Hill.

“Our collective action in patient safety pales in comparison to the magnitude of the problem,” said Dr. Peter Pronovost, senior vice president for patient safety and quality at Johns Hopkins Medicine. “We need to say that harm is preventable and not tolerable.”

Dr. Ashish Jha, a professor at the Harvard School of Public Health, said patients are no better protected now than they were 15 years ago, when a landmark Institute of Medicine report set off alarms about deaths due to medical errors and prompted calls for reform.

“We can’t continue to have unsafe medical care be a regular part of the way we do business in health care,” Jha said.
read the full article

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

Infographic on the GE ANA survey of Nurses and Patient Safety

In High Reliability Orgs, Safety climate on August 7, 2013 at 7:54 am

I made this infographic from the data from GE + ANA global survey of nurses

Read press release

Fake Fixes

In High Reliability Orgs, Patient Safety, Safety climate on February 5, 2013 at 12:07 pm



Read this op-ed piece from the Times by the author of “Bad Pharma…”

(Ben has an interesting website:

How should we handle omission of information?

Is dont ask dont tell dangerous for healthcare?

some hightlights from op-ed:

“Trials with positive or flattering results, unsurprisingly, are about twice as likely to be published — and this is true for both academic research and industry studies”

“These problems would be bad enough on their own, but they are compounded by a generation of “fake fixes” that have delivered false reassurance, and so prevent realistic public discussion.”

“All of these problems are perhaps best illustrated by the case of Tamiflu, which governments have spent billions of dollars stockpiling, in the belief that the drug will reduce the rate of complications from influenza. But roughly half the trial results have never been published, and researchers trying to obtain the full Clinical Study Reports have been stonewalled by the manufacturer, Roche.”

“This cannot be acceptable. Withholding data not only misleads doctors and patients; it’s an insult to the patients who have participated in clinical trials, believing that they were helping to improve medical knowledge.”


When productivity trumps safety we all lose.

In human error, Normal Accident Theory, Resiliency, Safety climate on September 30, 2012 at 9:32 am

““You are judged by numbers in the lab,” McShane said. “There is a culture of pressure to get it done with no new ­resources. But there is no ­excuse for [cheating] at the end of the day.” (, 2012)

So goes the story of Annie Dookan, a chemist in a Massachusetts crime lab who is suspected of compromising evidence in many of the 34000 samples she has tested in her 9 year career.  Her motivation seems to be no more nefarious than trying to look like a stellar employee.

What does this have to do with patient safety? It is common in hospitals today to push the border in terms of productivity.  Add some more patients, add new procedures, add no more  staff.  In safety studies this can result in what is known as drift.  You get through one shift with suboptimal staffing and nothing bad happens so you chance it again, then again, and little by little in order to cope: staff develop workarounds and short cuts that all begin to be seen as normal (culture) and less risky as staff has not gotten feedback on any bad results. If staff continue to be judged on output (census, patient turnover, lower expenditures) they will seek to make these their priority rather than follow safe procedures.

According to Cook (2000) work processes do not chose failure but drift toward it as production pressures and change erode the defenses that normally keep failure at a distance. “This drift is the result of systematic, predictable organizational factors at work, not simply erratic individuals.  To understand how failure sometimes happens, one must first understand how success is obtained-people learn and adapt to create safety in a world fraught with gaps, hazards, trade-offs, and multiple goals.”

In safety critical environments that deal with people’s lives, leaders should be preoccupied with failure not productivity. A leader is responsible to identify drifts by being present in daily processes. Drifts can be identified by observing staff behaviors, reviewing peer reports and asking people what types of things they are worried about. Asking staff to “do their best” without a supporting environment will not result in a high performing system. Productivity goals should be made based on an analysis of the work not by how much money is in the budget. I think it’s time as a nation we say in all instances “if there isnt enough money to do things right, don’t do them at all.”

 Annie Dookin made some bad choices but she worked in an environment where bad choices were acceptable and when peers did speak up, nothing was done. Who is responsible for this?

And who is responsible for the incarceration or punnishment of some people who might be innocent who are imprisoned: all because a culture of productivity over-ranked safe procedures. In these circumstances, just as in healthcare, humans always suffer.

Safety first. Productivity second. These cannot just be words and slogans. They have to be guiding principles that are evident in everything we do, in healthcare and in crime labs.  It scares me that this lab was run by……..The Department of Public Health 😦

Where are we safe? Stay home and watch this movie.

In Patient Safety, Safety climate on July 26, 2012 at 3:16 pm

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!


In human error, Patient Safety, Safety climate on September 25, 2011 at 8:00 am

Hand Hygiene?
Yes, but so much more. Please view this graphic entitled “Hospital Hazards” at Mark Graban’s Lean blog.

Some highlights:
“You are 33,000 times more likely to die from a hospital error than from a plane crash.”
“Mistakes in hospitals cost the US $17 billion each year.”
“Fifty percent of Doctors neckties have been found to harbor dangerous pathogens.”

Can’t we fix this?

Review of “Do Strikes Kill?”

In I-O Psychology, Patient Safety, Resiliency, Safety climate on May 6, 2011 at 9:25 am

Healthcare workers have had the right to strike since 1974. By 2008 there were over one million hospital union workers.  While other industries had declining union memberships, hospital employees’ unionization is growing (Gruber & Kleiner, 2010).

Do Strikes Kill is the provocative title of a working paper by Jonathan Gruber and Sam Kleiner (MIT and Carnegie Mellon).

All hospital employees are imperative to providing safety in a hospital environment, but the authors looked at nurses in particular. They cite Kruger & Metzger (2002) when they describe that nurses function as “the surveillance system of hospitals for detection and intervention when patients deteriorate, and are viewed by many patients as more important to their total recuperation process than their own attending.”  Another CEO was quoted as describing nurses as “the heart and soul of a hospital” (Gruber & Kleiner, 2010).

Given this integral role for nursing, the authors sought to determine the impact on safety and quality in the events of nursing work stoppages. They looked at data over a 20 year period in New York State.  For patients admitted to hospitals during a nursing strike, the authors found MORTALITY increased by 19.4% and readmissions within 30 days increased by 6.5%.

I recommend purchasing this relevant study for $5 at the National Bureau of Economic Research website:

To understand the safety implications for your own institutions, it is important to look at the details of this study and not just the overall results.

At one time, Industrial-Organizational psychologists were employed as union “avoidance consultants.”  They had success through improving the work environment for employees.  While labor lawyers can be a resource for a hospital in interpreting labor laws, an Industrial-Organizational Psychologist can combine theory and practice to improve culture, employee satisfaction, teamwork, front line empowerment, training, leadership approaches and development, quality and many other workplace happiness indicators.  It’s the right thing to do but also Happy Employees aren’t likely to strike.

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