Safety culture is the ways in which safety is managed in the
workplace, and reflects the attitudes, beliefs, perceptions and
values that employees share in relation to safety. In other words
“the way we do safety around here.”
Several reports in the CHPSO database have pointed to the
inaccessibility of spare surgical parts or tools while a
procedure is in progress. In several cases, unique screwdrivers
or drill bits have broken, or unique-size screws went missing. In
at least one instance, the incision had to be temporarily closed
with an implant partially secured and the patient was scheduled
for re-operation to complete the procedure another day.
The following scenario is derived from incidents reported to CHPSO:
A stable, ventilator-dependent patient (KP) was placed in a room across from the nurses’ station. The nurse caring for this patient then received a post-operative patient whose condition was deteriorating. A code was called for the post-op patient and several staff in the area responded to assist. During this emergency, KP’s ventilator tubing had become disconnected and the ventilator started alarming. However, no one responded to the alarm until a custodian passing by approached the nurses’ station and notified the unit clerk that he had noticed an alarm coming from KP’s room for several minutes and wanted to make sure someone was notified. At this point, the clinical staff realized that KP was quickly deteriorating and immediately responded. Unfortunately, they could not resuscitate KP.
Diffuse responsibility is a recognized safety concern in clinical alarm management. In order to manage the large amount of noise in busy and monitored environments, clinicians often “tune out” alarms that are not related to their own patient assignment. There is an underlying assumption that someone else is responding to an alarm associated with another clinician’s patient. Personnel in the area who are not clinicians are intimidated by alarms and assume that a clinician will respond. One approach to solving this issue is to implement the “No Pass Zone.”
In an era dependent on technology to make our lives easier,
patients continue to suffer from severe complications with
medical devices. While the FDA monitors problems associated with
medical devices, some devices require thoughtful design and
sufficient research before the devices are rushed to market. As
part of the research, such devices require a close look at how
they work within a system. Some devices receive the proper
research1 after it is made publicly available, when
end-users unintentionally go through a trial-and-error phase.
In my last column, I discussed the critical role of leaders in
shaping organizational culture. Here we take the next step
and look at the requirements for achieving high reliability.
Given high rates of adverse events, process failures and patient
harm, the idea of achieving high reliability in healthcare may
seem absurd. Even so, many well-respected healthcare leaders have
sounded the clarion call to make this the primary goal.
In my last column, I discussed that many American hospitals are
characterized by a culture of blame: one that is antithetical to
the pursuit of patient safety and high reliability via
My research has shown that roughly 20 percent of hospitals make
significant changes in their clinical peer review program’s
structure, process or governance every year. Unfortunately, this
high rate of change has not resulted in substantial improvement.
Much of the recent change has concentrated on the replication of
a multi-specialty review process, with neglect of factors central
to the evidenced-based QI Model. You can refresh your
understanding of the QI Model through a brief online program
self-evaluation questionnaire at http://QAtoQI.com/set.htm.
The Quality Assurance or QA Model for clinical peer review has
far outlived its utility in meeting Joint Commission
requirements. Now, it only serves to perpetuate a culture of
blame and poison efforts to develop a culture of safety and
high-reliability. Because peer review remains the dominant method
by which adverse events are examined, the mode in which it is
conducted has far-reaching effects. Progress in patient safety
will be stymied until the model is changed.
The QA Model has dominated medicine for 30 years. Enough time has
passed for the current generation of physicians to believe that
the model is sacrosanct: “It’s the way we’ve always done it and
the way it should be done.” The medical profession has, however,
used other methods. Peer review has been documented as early as
the 11th century and may have originated in ancient Greece.
Modern practice emerged from Codman’s End Results System and
Ponton’s concept of Medical Audit.
If you’ve been following this column, you know that the majority
of hospitals suffer from a culture of blame that poisons efforts
to improve quality and safety. The dysfunctional Quality
Assurance (QA) Model for Clinical Peer Review is a major part of
the problem. It perpetuates the negative cycle of blame and fear
by focusing on competence and punishment rather than on
In the May issue of CHPSO Patient Safety News, this column
focused on the importance of learning from defects and pointed
out the problem with identifying adverse events, near misses and
hazardous conditions. This is not a small problem. Typically,
only about 10 percent of adverse events are reported. This means
that either much effort must be expended to identify such cases
by other means or that many learning opportunities will be
Now that we have gained a common vision of possibilities for a QI
Model of peer review, it will be useful to return to our
framework for improving patient safety to take a deeper dive into
learning from defects.
In my last column, I reviewed the basics of extracting valid
measures of clinical performance during case review. It turns out
that such measures can be of great benefit in minimizing bias in
peer review. The key is to remember that measures of clinical
performance require an aggregate view over multiple cases. They
are not reliable enough to justify harsh corrective action based
on a single case.This fits well with the QI model for peer
review.When each case review is not a threatening, high-stakes
exercise and the rating scale captures all shades of gray, life
In my last column, I outlined the three primary modes of
organizational learning and highlighted the opportunity to
measure clinical performance during peer review. Clinical
performance measures can be used to promote self-correcting
behavior through timely performance feedback. They can also serve
to identify performance trends among groups of clinicians.
Extracting such measures greatly increases the efficiency and
value of peer review. Let’s see how.
In my last column, I highlighted the fundamental differences
between the old, dysfunctional QA style of peer review and the
more effective QI Model. Let’s now put that in the context of how
healthcare leaders create the learning necessary to improve
Complex systems, such as hospitals, are inherently unsafe and
culture is the key to getting and keeping patients safer. A Just
Culture is defined as an environment of trust and fairness where
it is safe to report and learn from mistakes and system flaws. It
is where we are clear about the difference between human error in
complex systems and intentional unsafe acts.
A Fair and Just Culture is where reporting and learning are
valued, people are encouraged and rewarded for providing
essential safety-related information and leaders and human
resource systems assure we achieve it.
In my last column, I told the story of how I first came to test
my assumption that clinical peer review would be forever
antithetical to quality improvement.Today, I’d like to outline
for you the characteristics that differentiate a QI model for
peer review from the dysfunctional, legacy QA model.The QI model
frames peer review as a quality improvement activity, not only to
improve the process itself, but to better support the effort to
improve clinical performance and patient safety.It’s a battle for
the hearts and minds of the medical profession that will affect
nursing as well: the way w
Information for this case was obtained from newspaper accounts.
See references for details.
A 10-fold overdose of calcium chloride contributed to the death
of an infant on September 19th of last year. According to the
family, a nurse accidentally miscalculated the dose. After an
investigation, the hospital changed its policy to allow only
pharmacists and anesthesiologists to access calcium chloride in
On March 23, 2005, a fire and explosion occurred at BP’s refinery
in Texas City, Texas, killing 15 workers and injuring more than
170 others. A multitude of equipment failures and human decisions
contributed to the disaster. To date, BP’s fines and victim
compensation expenses are over $1.7 billion.
One year after the event, BP’s Senior Group Vice President,
Safety & Operations, addressed the Second Global Congress on
Launching Crew Resource Management (CRM) training can help smooth
the path toward a just culture. That’s because CRM builds the
behaviors and attitudes that increase patient safety. By learning
about and practicing essential CRM and other human factor skills
— which encourage safe behavior and reduce error — teams operate
more effectively and efficiently in any safety culture. CRM
strengthens this culture by helping you and your team:
Owing to the generosity of Thomson Reuters and Premier Inc.,
electronic reprints of the latest findings on clinical peer
review effectiveness will be available at no cost until the end
of May. The article appears in the April issue of the American
Journal of Medical Quality. The publisher usually charges a fee
of $20 for each download to non-subscribers.