10/4/2012. Disclosure. Leading a Meaningful Event Investigation. Just Culture definition. Objectives. What we all have in common

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1 Leading a Meaningful Event Investigation Natasha Nicol, Pharm D, FASHP Director, Medication Safety Cardinal Health Disclosure I do not have a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias my presentation. Objectives Just Culture definition Define severity bias and why this should be avoided when investigating an event Demonstrate the basics of building a cause and effect diagram Discuss the importance of realizing the causes behind risky behavior Explain the need to search for the causes of an error as the means to learn and build risk reduction strategies Describe the importance of front line staff s input to every investigation Workers trust each other, are rewarded for providing safety information, and are clear about their responsibilities regarding safe behavioral choices. There is a shared accountability. What we all have in common Fallible humans and human behaviors Imperfect systems Potential for faulty equipment A set of values (though they are specific to us) Types of behavior involved in errors Human Error: an inadvertent action; inadvertently doing other than what should have been done; slip, lapse, mistake At-Risk Behavior: a behavioral choice that increases risk where risk is not recognized, or is mistakenly believed to be justified Reckless Behavior: a behavioral choice to consciously disregard a substantial and unjustifiable risk 1

2 Personal Performance Shaping Factors These must be managed when designing systems Affect the rate of human error (and at-risk behavior): - stress - fatigue - environment - distractions - procedural design - communication Managing Human Error Two Questions: 1 Did the individual make the correct behavioral choices? 2 Is the individual id effectively managing their own performance shaping factors? If yes, the only answer is to console the individual the error also happened to them AND Examine the system for improvement opportunities 8 Consoling Human Error A Conversation to Learn Discussing why the event happened and what can be done to prevent it from happening again Risky Business In those states that have enacted laws against texting while driving, has the accident rate gone up or down? Help by comforting the employee Remember, the manager also investigates the system and makes changes as appropriate ***Also remember that the employee made the mistake, not the choice 9 10 How are you managing your risk? It s all about the perception of risk Do you know your vulnerabilities? Your employees do! What At-Risk behavior is occurring? At-Risk Behavior is a choice: Risk believed to be insignificant or justified /Like father like son Baby Bob Irwin feeds alligators late daddy Steve sanimal park aged just EIGHT.html 2

3 Coaching at-risk behavior Create a learning opportunity: - understand their point of view - describe the at-risk behavior - explain how this behavior isn t aligned with our values - create an action plan Drinking and Driving clearly Reckless Reckless Behavior is a conscious disregard of a substantial and unjustifiable risk >13,000 deaths per year Managing reckless behavior Disciplinary action Punishment Punitive action Remember in a Just Culture Shared accountability: Employer: create safe systems Yes, I said punitive!!!!! Employee: make safe behavioral choices Investigation of Events Do not regard an event as something to be fixed An event is an opportunity to understand risks -system - behavioral Keep in mind, the system is comprised of sometimes: - faulty equipment - imperfect processes - fallible humans Questions to ask What happened? What normally happens? What does procedure require? Why did it happen? How were you managing it? 3

4 Remember: Public perception or truth? It is the causes of the error that give us the data we need in order to begin to work on and build risk-reduction strategies Intro to Event Investigation Rules of the day Example case Scenario The NICU nurse goes to the automated cabinet to retrieve heparin 1,000 units/ml for her patient. Without looking into the bin, she grabs a vial. She draws up the medication and administers it to the patient. Unbeknownst to her, the pharmacy technician had refilled the bin incorrectly with 10,000 unit/ml heparin. Avoid Severity Bias Harm vs. no harm How do you handle the situation? no harm, no foul doesn t work in a Just Culture Choose your own adventure: a. The child was not harmed b. The child suffered severe bleeding and his survival is in question 4

5 Step 1: Identify the undesirable outcome Step 2: Begin looking for causes Are there more than one? What happened? What normally happens? What does procedure require? Step 3: Build a cause and effect diagram Begin with placing the outcome(s) on the right side of the page Build the diagram from right to left (include all information that could be causal) Ensure all causes have a reasonable link to their effect (can you prove it?) (cause of the behavioral choice) (behavioral choice) (human error) (outcome) (cause of the human error) Step 4: Explain the human error(s) What behaviors were exhibited? - Human error (any performance shaping factors increasing chance for error?) - At-risk - Reckless Every human error should have a preceding cause (cause of the behavioral choice) RN did not read the label on drug (behavioral choice) Pharmacy stocked the drug incorrectly (human error) (outcome) (cause of the human error) 5

6 Step 5: Explain the violations What were the perception(s) of risk? Every at-risk behavior should have a preceding cause System performance shaping factors? Every system deviation should have a preceding cause Individual performance shaping factors? RN always got right heparin from this pocket; felt no need to read label (cause of the behavioral choice) Why? RN did not read the label on drug (behavioral choice) Pharmacy stocked the drug incorrectly (human error) (outcome) (cause of the human error) Step 6: Explain any mechanical failures Was it reasonable to expect this failure? Why/why not? Step 7: Describe direct and potential causes Remove any data that is non-causal A caused B (direct) A increased the likelihood of B (potential) Ensure biases are removed Probable Cause Direct Cause Remember. RN always got right heparin from this pocket; felt no need to read label (cause of the behavioral choice) Why? RN did not read the label on drug (behavioral choice) Pharmacy stocked the drug incorrectly (human error) (outcome) It is the causes of the error that give us the data we need in order to begin to work on and build risk-reduction strategies (cause of the human error) 6

7 Step 8: Applying the Algorithm Just Culture Algorithm Take each person involved through the Just Culture Algorithm Event A nurse did not scan the wristband that was on the patient in bed A for positive identification during a med pass, she scanned a sticker. The patient received bed B s hydromorphone. The patient in bed A had an anaphylactic response, had to be intubated and treated with naloxone, and was transferred to ICU. The patient fully recovered with no permanent harm. Upon further investigation, the nurse indicated she always keeps stickers on the charts to use because the wristbands rarely scan. Building your diagram Outcome: patient received unauthorized medication Human error: did not scan patient (drifting? risky?) Cause of the human error: Equipment failure Find out what about the equipment failed and why System not adequate RN forced to create a work-around Find out why Event A 32-year old frequent flyer alcoholic male arrived in the ER unresponsive, accompanied by his mother. The ER physician gave a verbal order for fosphenytoin to the nurse, who went to the automated dispensing cabinet and retrieved the dose. The dose she thought she heard was 10 times what the physician intended. The nurse drew up all eight 10-ml vials and gave them IV push. The patient immediately began to seize violently and then coded. Resuscitation efforts were unsuccessful. The distraught mother said to the nurse: I knew his drinking would kill him one day. The nurse said nothing. Building your diagram Outcome: patient received wrong dose Error: nurse drew up and administered wrong dose Behavioral choice: Nurse did not verify dose with physician i Nurse took a verbal order Nurse unfamiliar with dosing for this medication Nurse did not review information for medication or call pharmacy Cause of the behavioral choice: Nurse did not want to seem incompetent Nurse trusted the physician/did not want to question him 7

8 Continue with Diagram Cause of the human error: Pharmacy stocked 10 vials in the ED No limitations or warnings with automation when retrieving this medication References not easily obtained; cumbersome to read Remember. It is the causes of the error that give us the data we need in order to begin to work on and build risk-reduction strategies Step 8: Applying the Algorithm Just Culture Algorithm Take each person involved through the Just Culture Algorithm 8