Author: phrampus

When a patient safety incident or a near miss occurs and is reported, decisions are made about what to do following the event and how to determine the level of investigation, if any, the event will require. Incident investigations can entail anything from a review of the record to conducting a full Root-Cause-Analysis (RCA) process.

An RCA provides a detailed review of the facts as they appear in the record, and includes interviews with individuals involved in the event — as well as managers and peers — to capture their recollections and recommendations. Additionally, the RCA process evaluates the role that the system played in the event.

The RCA asks critical questions such as:

1. Did policies, procedures, and processes exist?
2. If so, were they followed?
3. Were they relevant and appropriate to the event?
4. Were the appropriate resources available?

In some cases, the RCA is satisfied with a detailed investigation, but other times a face-to-face meeting with a comprehensive review is needed. The comprehensive review is particularly important when an incident involves many areas of care, providers, and/or clinical or operational departments. Meetings should happen as quickly as possible so the facts are still fresh in the minds of those involved in the RCA, 72 hours is preferred.

Scheduling an RCA meeting is a major administrative commitment that consumes valuable resources, but like every other tool or therapy in health care, we want to ensure that it happens when it is necessary and likely to bring value.

The decision to convene a face to face meeting typically involves the personnel of the institutions safety leadership that many times comprise of a Patient Safety Officer, Nursing Leadership and Physician Leadership.

The advantages of the well-done RCA are numerous.

They can uncover causalities of the event that are not obvious.

Nearly every patient safety incident has multiple root causes. An RCA allows deeper understanding of the situation and helps identify the multifactorial set of circumstances that contributed to the occurrence. Think of the James Reason Swiss Cheese model and apply it to patient safety. How many layers of the cheese had to line up to allow harm to reach the patient? The RCA helps to identify and correct the different processes that contributed to the error.

Sometimes, the cause of harm seems obvious and it is tempting to shortcut the investigation. This usually happens when the cause is determined to be related to individual competence. Caution is advised in these situations. Supervisors and leaders should not automatically assume an individual is the cause of the error, because it prevents us from investigating and identifying other aspects of the system (or additional causes) that could be contributing to error. The lack of examining process may leave the system, our patients, and care providers vulnerable to making a similar mistake and prevents us from learning.

They demonstrate to staff that there is great effort put into understanding and analyzing how the work environment can contribute to mistakes.

Presuming human error as the obvious cause of incident has other negative consequences. Maintaining a healthy safety culture is especially challenging when team members feel that mistakes are held against them. This perception of punishment prevents staff from feeling that they work in a just culture, a culture that enables learning and recovery, and recognizes process failures. 

Investigations can identify learning for the entire organization.

We need to create learning opportunities from patient safety incidents and near-misses. A detailed non-biased investigation will often uncover system issues that transcend a particular set of circumstances, clinical, or business unit. Lessons learned can be communicated to help increase the safety of patients throughout a given hospital, and ultimately, across the entire system. But a high level of learning is impossible without a search for the contributing factors.

Remember: If you are part of the decision-making team that is following up on a patient safety event or near-miss, consider the benefits of a well-conducted post-incident review to identify the root causes.

For an organization to develop system understanding and create a learning environment, the underlying causes need to be discovered and have the findings disseminated to prevent the same or similar events in the future.

As the Medical Director of patient safety for a large healthcare system I can say that conducting unannounced “mock codes” (Inpatient Crisis Response Evaluation System is the title of our program) is a critical pillar of safety quality improvement efforts. WISER oversees our program and provides the evaluation and consultation service to many of our 20 hospitals in conjunction with and close collaboration with the local hospital physician and nursing leadership.

The unannounced part allows true system evaluation of such a response. The events are closely choreographed with our simulation team (led by a physician medical director), as well as the local hospital leadership. Our evaluation system has afforded us as a system, the opportunity to unveil many latent system threats as well as identify opportunities for targeted training efforts. With regard to simulation and training it is a TRUE needs analysis in this way.

With regard to acceptance, I believe that it is related to the maturity of the overall organization and the simulation personnel conducting the events. In the words of James Reason on high reliability organizations “They anticipate the worst and equip themselves to deal with it at all levels of the organization. It is hard, even unnatural, for individuals to remain chronically uneasy, so their organizational culture takes on a profound significance. Individuals may forget to be afraid, but the culture of a high reliability organization provides them with both the reminders and the tools to help them remember.” Thus I believe in highly mature safety culture organizations it is incumbent upon both the leadership and the healthcare clinicians to be accepting of “external” evaluations for such critical moments as inpatient crisis events.

I also believe that the naming of the program has significant implications. The title “Mock Code” in my opinion sounds somewhat trivial, extra, perhaps of marginal utility, or at the very least “fake.” If that is the intent, then I believe that is easier to argue that the events should be pre-planned and/or avoid being completely “unexpected”. However if the intent is to seriously evaluate a high reliability organization’s response to an unexpected patient situation, and identify needs, process improvement opportunities and uncover latent threats, I would argue for the unannounced methodology.

Our health system shares a deep commitment to continue on the journey to high reliability and believe our Inpatient Crisis Response Evaluation System is an important component of our success. As WISER is accredited by the SSH in Systems Integration (among other categories) we believe a fully integrated approach is necessary, very safe, feasible and our responsibility to execute and provide feedback to our health system.

As anyone who provides actual care for patients there are risks and benefits to ALL decision that are made from therapeutics, to staffing, to salting the parking lot. There are certainly safety items that must be attended to in any of our simulation efforts, particularly those which occur in proximity to actual care. However carefully crafted programs, process and execution will ultimately ensure the benefits outweigh the risks.

I truly believe the undiscovered system latent threats to inpatients are a greater risk than the conducting of the mock code itself.

A Just Culture in a health care setting is one of the cornerstones of the overall culture of safety at a given institution. It exists when the staff understands that they are part of an organization that recognizes several important tenets of the work environment related to patient safety.

Those tenets include recognition that humans and systems are fallible and that errors and near misses occur. When they do, the humans in the system are treated fairly. Additionally, care providers need to know that the system hears their voice of concern and has a true desire to learn from such events.

The establishment of A Just Culture is part of a cultural transformation that allows an organization to move from a punitive response to errors to one in which health care professionals are expected to speak up and report potentially unsafe conditions. Such an environment allows health care providers to speak more freely about errors and to help create a safer environment for the future.

A Just Culture does not free individuals of personal accountability. Health care professionals make hundreds if not thousands of decisions on a regular basis that affect the patient care. They’re expected to make these decisions in accordance with their professional training, protocols, guidelines, and known best practices. A Just Culture should give people the confidence that when errors do occur, however serious, those involved will be treated fairly and equitably.

Organizations like ours with a high-functioning belief of the existence of A Just Culture understand the complexity of health care decision making. We recognize that many times health care professionals are making decisions based on professional judgment and situational awareness as well as the real-time interactions and needs of the patients within available resources. From the start, A Just Culture assumes that individual health care professionals have a desire to deliver the best care within their purview.

For decades in health care, errors and/or near miss occurrences invoked a punitive-orientated focus to investigations that largely sought to assign blame to the individual health care providers involved in the event. Many times, investigations are conducted with a mission of finding someone to blame instead of looking for the true cause(s) of the event. Investigations and remedies that focus on a punitive, pervasive thought process will also tend to fail to assess responsibilities and causes attributable to the system providing the infrastructure for the health care providers.

The end result is one that creates an environment of mistrust in and amongst groups of professionals or teams that provide patient care daily. This perpetuates a “shame and blame” response to the errors. In such circumstances, it is not hard to understand the natural response to push the responsibility or blame to others involved in the incident. This creates a natural barrier to productive inter- and intra-professional dialog about the incident and inputs bias into the final report that attempt to deflect blame. Thus, it decreases the ability to be able to rely on, or learn from, information obtained in terms of attempting to create solutions or interventions that would likely reduce the chance of a similar occurrence in the future.

Investigations in a high functioning organization embracing A Just Culture will look for causes of incidents beyond the focus on an individual and seek to identify the many elements of system breakdown that often accompany errors and mistakes. Those of us working in patient safety truly understand to be able to improve systems to a level that would proactively prevent an error from occurring.

The foundation of culture is people. How people interact within a community is partly based on custom, tradition, trust, mutual respect, and some vision of purpose. A Just Culture is a journey that requires attention to all of these factors regarding professionals in community. In healthcare leaders must develop a strong commitment to maintain the principles of A Just Culture from the most senior leadership down to the individual providers who perform patient care on the front-line.