49th Annual Meeting Preventing Medication Errors in a Just Culture Environment 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 Jorge J. García PharmD, MS, MBA Director of Pharmacy Oncology Service Line Memorial Healthcare System OWNING CHANGE: Taking Charge of Your Profession Objectives Review transition from a Blame Free Culture to Just Culture Review accountability and disciplinary action plans Review of root cause analysis Discuss risk assessment strategies Discuss risk mitigation strategies Blame Free Culture Why should we promote a Blame Free Culture? Blame has an emotional context Blame shifts energy and focus Blame creates biases Blame inhibits creativity Blame is expensive Blame can kill Review practice safety updates Blame Free Culture Eliminating Blame How can blame be prevented? Polices and procedures Individual s emotions Self awareness Self management Culture change Process Focus Map process / behavior that created an undesirable result Process validity Avoid attributing results to characteristics of individuals 1
Eliminating Blame Eliminating Blame Alignment of Purpose Questionable core intent of others Foster Effective Communication Blame leads to communication crisis Self interest vs. common interest Self Assessment Self Assessment What do you first ask yourself when something didn t go as planned? Who did it? What part of the process allowed this to happen? Are you operating in a place of fear? What do you ask yourself when you do something wrong? How can I protect myself? How can everyone learn from this? Or in an environment of courage, growth, and learning From Blame Free to Just Culture From Blame Free to Just Culture Just Culture Set of values, beliefs, and norms about what is important, how to behave, and what behavioral choices and decisions are appropriately related to occurrences of human error or near misses. Excerpt From the Just Culture Toolkit. Blue Team Nursing. August, 2012. 2
Just Culture How do we get there? On the tracks to Just Culture Checklists Procedures and protocols CPOE order sets Medication barcode scanning Decision making training Model high reliability organizations Resilience Excerpt From the Just Culture Toolkit. Blue Team Nursing. August, 2012. Just Culture Recognizes errors are often system failures Requires full disclosure Mistakes, errors, near misses, safety concerns, sentinel events Is a culture of accountability Counseling Consoling Coaching Education Corrective action? Outcome Based Disciplinary Decision making The more severe the outcome, the more blameworthy the employee Flawed system based on notion that we can totally control the outcomes Criminal System Excerpt From the Just Culture Toolkit. Blue Team Nursing. August, 2012. Rule based Disciplinary Decision making Rule based Disciplinary Decision making Individual is liable if there is a violation of policy Most high risk industries have rules, polices, and procedures intended to prevent error Did an individual violate a rule? Did the individual intentionally violate the rule? Individual is liable if there is a violation of policy Avoid sole judgment on policy violation Focus on individual s knowledge that policy violation increased risk for potential harm Are all violations of rules/polices/procedures bad? 3
Disciplinary Action Plan Summary Risk based Disciplinary Decision making Individual is liable if they understood risk associated with behavior Assess employee s outcome intent Negligence Employee should have known Employee was unaware of risk Recklessness Intentionally taking significant and unjustifiable risk Griffith S. An Introduction to Just Culture. Outcomengenuity. 2012. Failure Mode and Effects Analysis (FMEA) Failure Mode and Effects Analysis (FMEA) Systemic, team based process designed to evaluate risk and reliability Mode way a process might fail Effect consequences of the failure Actions to reduce / eliminate failure Proactive approach What are the steps in the process? What can go wrong in each step? Why would it go wrong? What would be the consequences? How frequently will the process fail? How severe is the potential harm? How early/easily can failure be detected? How can one mitigate harm? Fibuch, E., Ahmed, A. The Role of Failure Mode and Effects Analysis in Health Care. Quality. August, 2014. Fibuch, E., Ahmed, A. The Role of Failure Mode and Effects Analysis in Health Care. Quality. August, 2014. High Reliability Organizations (HRO) Root Cause Analysis (RCA) Constant concern about possibility of failure Deference to expertise regardless of rank/status Ability to adapt when unexpected occurs Commitment to resilience Ability to concentrate on specific tasks while having a sense of the bigger picture Reactive process Identify the underlying causes of an error Full understanding of the problem before action plan is developed Thorough identification of all contributing factors 4
Root Cause Analysis (RCA) RCA Fishbone Diagram RCA Goals Determine causes of incident Identify breaks in the system Identify training needs Identify if more supervision is needed Reduce re occurrence Commitment to finding causes Commitment to develop a safer environment Where are we today? Institute for Safe Medication Practices (ISMP), American Hospital Association (AHA), Health Research and Educational Trust (HRET) ISMP Medication Self Assessment for Hospitals Anonymous survey (yr 2000) 1,400 hospital responses U.S. safety baseline Highest Scores Communication Computerized Prescriber Order Entry (CPOE) 6% 55% 817% Prohibited error prone abbreviations /dose expressions 18% 91% 406% Medication Administration Record (MAR) available at bedside 21% 77% 267% Not accepting verbal or telephone orders for oral or parenteral chemotherapy 50% 75% 50% Resurvey (yr 2011) 1,310 hospital responses Highest Scores Patient Education Provision of customized drug administration schedules to 31% 73% 136% patients at high risk of non adherence Potential for errors with drugs considered problematic 59% 81% 37% Written information about prescribed medications 83% 95% 14% Automatic pharmacy patient education at discharge 23% 39% 70% Highest Scores Quality& Risk Management Leadership and peer support to all staff involved in serious error 22% 64% 191% Disclosing actual medication errors to patients or families 55% 87% 50% Computer markers to enhance detection of potential ADE 62% 84% 36% Bar coding technology Pharmacy 10% 53% 430% Point of care 3% 58% 1833 % 5
Lowest Scores Patient Information Integration of inpatient & outpatient computer entry systems 31% 46% 48% Patient allergies as a required field 29% 44% 51% Patient weights as a required field 4% 13% 225% Lowest Scores Staff Competency Baseline competency evaluation prior to working independently 74% 77% 4% Float staff 30% 50% 51% Hospital actual error experiences shared with all clinical staff 24% 45% 225% Pharmacist orient all new medical staff on medication use and safety 13% 21% 62% Lowest Scores Drug Information Complete drug history for every inpatient an outpatient 37% 61% 65% Clinical decision support systems 9% 17% 89% Routine testing of information system to verify maximum doses 10% 36% 260% Conclusion Just Culture promotes an environment of safety and accountability Use proactive, risk assessment tools, and reactive, risk mitigation tools Hospitals with pharmacists working directly in the patient care unit 20% 43% 115% Each individual person plays a role in building a culture of safety 49th Annual Meeting Medication Errors in The Health System Setting Jorge Joanh García PharmD, MS, MBA Director of Pharmacy Oncology Service Line Memorial Healthcare System OWNING CHANGE: Taking Charge of Your Profession 6