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Errors:Errors: A Balance Between Learning A Balance Between Learning

and Accountabilityand Accountability

Presented to: The Michigan Health and Safety Coalition

April 14, 2004

David Marx, JD

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Let’s be Honest…

MENWOMEN

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Agenda

• An Introduction to Patient Safety and Just Culture

• Disciplinary Analysis• The “Just Culture”• Just Culture Implementation • Questions

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An Introduction to Discipline

“There are activities in which the degree of professional skill which must be required is so high, and the potential consequences of the

smallest departure from that high standard are so serious, that one failure to perform in

accordance with those standards is enough to justify dismissal.”

Lord DenningEnglish Judge

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An Introduction to Discipline

“People make errors, which lead to accidents. Accidents lead to deaths. The standard solution

is to blame the people involved. If we find out who made the errors and punish them, we solve

the problem, right? Wrong. The problem is seldom the fault of an individual; it is the fault of

the system. Change the people without changing the system and the problems will continue.”

Don NormanApple Fellow

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An Introduction to Discipline

The single greatest impediment to error prevention in the medical industry is

“that we punish people for making mistakes.”

Dr. Lucian LeapeProfessor, Harvard School of Public Health

Testimony before Congress on Health Care Quality Improvement

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An Introduction to Discipline

“…No person may operate an• aircraft in a careless or reckless manner so

as to endanger the life or property of another.”

Federal Aviation Regulations§ 91.13 Careless or Reckless Operation

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An Introduction to Discipline

“As far as I am concerned, when I say “careless” I am not talking about any kind of “reckless” operation of an

aircraft, but simply the most basic form of simple human error or omission that the Board has used in

these cases in its definition of “carelessness.” In other words, a simple absence of the due care required under the circumstances, that is, a simple act of

omission, or simply “ordinary negligence,” a human mistake.”

National Transportation Safety Board Administrative Law Judge

Engen v. Chambers and Langford

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NCSBN Model Nursing Practice Act

IX. Discipline and Proceedings, e. Unsafe Practice/Unprofessional Practice

1. Failure or inability to perform registered nursing, practical nursing, as defined in Article II, with reasonable skill and safety.

2. Unprofessional conduct, including a departure from or failure to conform to board standards of registered nursing, practical nursing, or advanced practice nursing.

6. Conduct or any nursing practice that may create unnecessary danger to a client’s life, health or safety.

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An Introduction to Discipline

  WASHINGTON

 1999 serious action rate: 2.49/1000 doctors1999 ranking: 37th

In Washington, there were disciplinary actions reported against 408 doctors including 11 who were disciplined for substance abuse, 25 for misprescribing or overprescribing drugs, 28 for sexual abuse of or sexual misconduct with a patient, 55 for substandard care, incompetence or negligence and 9 who were convicted of a crime.

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The Tension

• To improve patient safety, we must make better use of minor human error events

• The threat of corporate disciplinary action and regulatory enforcement is a major obstacle to event reporting and investigation

• The role of disciplinary action must be addressed

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Disciplinary Decision-Making

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The Four Evils?The Words You Use Today

Reckless Behavior

(gross negligence)

Negligent Behavior(carelessness)

HumanError

KnowingViolations

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Distinguishing Negligent and Reckless Behavior

• Negligence– Should have been aware

of a substantial and unjustifiable risk

– Equivalent to social definition of human error

– A compensatory concept in the law

• Recklessness– Conscious disregard of a

substantial and unjustifiable risk

– A punitive concept in the common law

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The “Just Culture”

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Human Reliability

The Human Reliability Curve

Factors Affecting Human Performance(including personal behaviors)

Poor Good

HumanError

SuccessfulOperation

100%

0%

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Managing Risk – The Three Behaviors

At-Risk Behavior

Unintentional Risk-Taking

Reckless Behavior

Intentional Risk-Taking

Manage through:

• Disciplinary actionManage through:

• Understanding our at-risk behaviors

• Removing incentives for at-risk behaviors

• Creating incentives for healthy behavior

• Increasing situational awareness

Normal Error

Product of ourcurrent

system design

Manage through changes in:

• Processes

• Procedures

• Training

• Design

• Environment

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A Just Culture

• A Set of Beliefs– A recognition that professionals will make

mistakes– A recognition that even professionals will develop

unhealthy norms– A fierce intolerance for reckless conduct

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A Just Culture

• A Set of Duties– To raise your hand and say “I’ve made a mistake”

– To raise your hand when you see risk

– To resist the growth of at-risk behavior

– To participate in the learning culture

– To absolutely avoid reckless conduct

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Implementing a Just Culture

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Create a Safety-Supportive Policy

HOSPITAL WIDE POLICYPolicy #: 6.350Page#: 1 of 3Origination Date: 5/03Reviewed: 6/03

Revised:SUBJECT: NON-PUNITIVE CULTURE

PURPOSETo encourage reporting of adverse medical events, near misses, existence of hazardous conditions, and related opportunities for improvement as a means to identify systems changes which have the potential to avoid future adverse events. To provide guidelines for the application of non-punitive processes versus disciplinary actions.POLICYPVHMC encourages reporting of all types of errors and hazardous conditions. The organization recognizes that if we are to succeed in creating a safe environment for our patients, we must create an environment in which it is safe for caregivers to report and learn from errors.It is recognized that competent and caring associates may make mistakes and it is the intention not to instill fear or punishment for reporting them.There must be a non-punitive, supportive environment for all staff to report errors and near misses.Error and near miss reporting are a critical component of the PVHMC patient safety and risk management program.Errors and accidents should be tracked in an attempt to determine trends and patterns to learn from them and prevent a reoccurrence, thus improving patient safety.The focus is on how systems and processes can be improved to help people avoid mistakes in the futureIn the process of evaluating errors and near misses, healthcare providers participate in reporting and developing improved processesGUIDELINESThe focus of the program is performance improvement, not punishment. Employees are not subject to disciplinary action when making or reporting errors/injuries/near misses except in the following circumstances:The employee repeatedly fails to participate in the detection and reporting of errors/injuries/near misses and the system-based prevention remedies.There is reason to believe criminal activity or criminal intent may be involved in the making or reporting of an error/injury.False information is provided in the reporting, documenting, or follow-up of an error/injury.The employee knowingly acts with intent to harm or deceive.Reckless acts

• State the Purpose

• Draw the Bright Line

• Set the Expectations

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Modify Your Toolset

• Safety-oriented event investigation– Explain every error– Explain every violation– What do events say about “future” risk

• Begin thinking prospectively– Chronic unease– Failure Modes and Effects Analysis– Probabilistic Risk Assessment– Proactive At-Risk Behavior Analysis

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Train the Management Team(an example curriculum)

• Just Culture and Patient Safety

• An Intro to Human Error• Managing Normal Error• Managing At-Risk

Behavior• Managing Reckless

Behavior

• Event Reporting and Investigation

• The Investigation Process

• The Role of Peer Review

• Making System Changes

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Conclusion

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Even the best of us are going to make mistakes…

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… it’s our response that will make the difference

• It is more of what we teach our kids– An expectation that

errors will be reported (transparency)

– No expectation of perfection

– Accountability for choosing to take risk

– Expectations set at system level

– Expectation that system safety will improve

• It is not Hammerhead (or Whack-a-Mole)

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Questions?