Just CultureApplication

Identifying At Risk Behaviors

Stephanie Sobczak & Jill HansonQuality Improvement Managers

WHA

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Today’s CallApplication – At Risk Behaviors• Rules of Causation – brief review• Case examples using the Just Culture algorithm• Next 30 days

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Courtesy Reminders: •Please place your phones on MUTE unless you are speaking (or use *6 on your keypad) •Please do not take calls and place the phone on HOLD during the presentation.

ACTION ITEMS

Assess your current event investigation processes

Using an in-house scenario, have your JC team walk thru an event investigation process

Be prepared to discuss on webinarPlease send a scenario examples (for our Spring webinar discussions)

Past 30 Days

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Poll Question – 30 Day AssignmentWhat did you find as a result of the walk-

through of your event investigation process?

a. Our process aligns well with Just Culture and we do a good job.

b.Our process could be better, more consistent.c. We didn’t have an opportunity to complete

the walk-through.

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Group DiscussionWhat were your biggest “ah-ha’s” from the past

30 days:• Assessing your event investigation process• Walking through an event investigation

process using a real scenario

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Courtesy Reminders: •Please place your phones on MUTE unless you are speaking (or use *6 on your keypad) •Please do not take calls and place the phone on HOLD during the presentation.

Causation Rules Review1. Causal statements should clearly show the “cause

and effect” relationship.2. Negative descriptors should not be used in causal

statements (i.e., poorly, inadequately, etc).3. Each human error should have a preceding cause.4. Each behavioral choice/violation should have a

preceding cause.5. Failure to act is only causal when there was a pre-

existing duty to act.

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Another Way to Assess Event Investigation Causal Mapping

Scenario One

Group Discussion

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Joe was a veteran medical technologist in the laboratory. His co-workers noticed that he was starting to cut corners and not follow all procedures. Staff communicated their concerns to the manager, however no action was taken.

A cardiac patient was admitted to the ED and a brand new phlebotomist was sent to collect the blood samples. The new phlebotomist drew the blood samples at a site above a running IV with potassium (which is bad because you are basically drawing IV fluid which will make the lab tests wrong).

Joe ran the samples in the chemistry lab and got a panic level high potassium, which he called to the ED. Joe did not follow the standard procedure of requesting a second blood specimen to verify the panic level test result.

The ED treated the patient for high potassium and the treatment caused the patient to suffer a cardiac arrest.

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Increasing value

Event Investigation Steps

Scenario One Questions

• What would you need to know from the event investigation?

• Which duty(ies) was breached in this scenario?

• What would be your assessment using the algorithm: Human Error? At-risk Behavior? Reckless Behavior?

• What action would you take based on your assessment?

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Scenario Two

Group Discussion

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Sue, a med-surg RN, returned to work after being treated with chemotherapy for cancer. Upon Sue’s return, co-workers began to notice she was making frequent mistakes and didn’t appear to be thinking clearly. They raised their concerns with the unit manager, who was slow to act on the concerns.

Sue had a diabetic patient in room 248 and another patient next door in room 250. The CNA performed a bedside glucose on the diabetic patient in room 248 and verbally communicated the normal blood sugar results to Sue. Sue wrote the blood sugar down as 250 on her clipboard. Sue then proceeded to give the patient insulin, bypassing the EMR alert to verify the blood sugar. Mary, the CNA working with Sue, noticed the shortcut and notified her supervisor.

In the discussion with the supervisor, Sue concluded she mixed up the patient room number (for patient next door) and the actual blood sugar. She also seemed unaware of how to use the EMR blood sugar reading alert.

It was determined Sue likely had cognitive impairment due to her illness. She was referred for cognitive testing, but quit before the testing was completed.

Scenario Two Questions

• What would you need to know from the event investigation?

• Which duty(ies) was breached in this scenario?

• What would be your assessment using the algorithm: Human Error? At-risk Behavior? Reckless Behavior?

• What action would you take based on your assessment?

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Scenario Three

Group Discussion

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Recently, there has been a big increase in patient load within the outpatient Rehab Services department. Patients have begun to complain about their appointments starting very late.

On this particular day, a patient emerged from a treatment room asking if the Physical Therapist was coming back. The patient reported being left alone in the exam room with an ice pack on for 40 minutes.

The Physical Therapist had gone home for lunch. His next patient arrived at 1:00, and he had not returned from lunch yet. When the Assistant called at 1:15, the Physical Therapist was woken up by the call – he indicated he had “fallen asleep”.

The Physical Therapist had been coached several times previously about staying on schedule during the workday.

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Scenario Three Questions

• What would you need to know from the event investigation?

• Which duty(ies) was breached in this scenario?

• What would be your assessment using the algorithm: Human Error? At-risk Behavior? Reckless Behavior?

• What action would you take based on your assessment?

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AlgorithmHands On Practice Example

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Prior to June webinar Use the algorithm to walk through a recent employee discipline scenario.

Be prepared to share with the group what insights you discovered as a result.

The Next 30 DaysACTION ITEMS

Modify your existing event investigation processes (if needed)Use the Just Culture Algorithm to walk through a recent employee discipline scenarioBe prepared to discuss how the algorithm walk thru went during June’s webinar

Sharing Your Scenario Examples (choose one):• Send in a safety scenario example• Schedule a Just Culture scenario interview with WHA

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Thank You!Questions?

June 5th Just Culture Webinar10-11 am

Consoling Employees

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