Delivering Patient SafetyDelivering Patient Safety

2.2.

CHANGING THE CHANGING THE CULTURECULTURE

Professor James ReasonProfessor James Reason

These discussion materials do not follow These discussion materials do not follow the exact running order of the video the exact running order of the video

programme. They are intended to extend programme. They are intended to extend the reach of the project by facilitating the reach of the project by facilitating exploration of error management in exploration of error management in greater depth and the application of greater depth and the application of

these principles to local issues.these principles to local issues.

- Professor James Reason- Professor James Reason

OverviewOverview

What is culture?What is culture? The journeyThe journey Building a safe cultureBuilding a safe culture

The trouble with culture . . .The trouble with culture . . .

Is that it has about as much definitional precision as a cloud

Is that it has about as much definitional precision as a cloud

Safety culture

Yet . . .Yet . . .

Commercial aviation has a high degree Commercial aviation has a high degree of uniformity across world with regard to of uniformity across world with regard to equipment and standards.equipment and standards.

But the chances of being involved in an But the chances of being involved in an accident with one fatality vary across accident with one fatality vary across world by a factor of x 42 (1 in 11m to 1 world by a factor of x 42 (1 in 11m to 1 in 260k)in 260k)

Some of this is down to infrastructure, Some of this is down to infrastructure, but mostly it’s about culture.but mostly it’s about culture.

Safety culture

Culture: A workable Culture: A workable definitiondefinition

Shared values Shared values (what is important)(what is important) and andbeliefs beliefs (how things work)(how things work) that interact that interactwith an organization’s structure and with an organization’s structure and control systems to produce behaviouralcontrol systems to produce behaviouralnorms norms (the way we do things around here).(the way we do things around here).

Safety culture

What is a ‘safe’ culture?What is a ‘safe’ culture?

A safe culture = an informed cultureA safe culture = an informed culture An informed culture is one that knows An informed culture is one that knows

where the ‘edge’ is without having to fall where the ‘edge’ is without having to fall over it first.over it first.

An informed culture is preoccupied with An informed culture is preoccupied with the possibility of failure and works the possibility of failure and works continuously to become more resilient to continuously to become more resilient to its operational hazards.its operational hazards.

Safety culture

A safe culture has many A safe culture has many interlocking elementsinterlocking elements

Reportingculture

Justculture

Flexibleculture

Learningculture

Safety culture

The elements must work The elements must work in harmonyin harmony

Safety culture

Steps along the waySteps along the way

VulnerableSystem

Syndrome

High Reliability

Organisation

The journey

Vulnerable System Vulnerable System SyndromeSyndrome

Three core pathologiesThree core pathologies• Blame• Denial• And the pursuit of (the wrong

kind of) excellence

The journey

Why the urge to blame Why the urge to blame individuals is so strongindividuals is so strong

Attribution errorAttribution error Illusion of free willIllusion of free will Just world hypothesisJust world hypothesis Hindsight biasHindsight bias Managerial convenienceManagerial convenience Legal convenienceLegal convenience Appeasement of patients Appeasement of patients

& relatives& relativesThe journey

Penalties of blaming Penalties of blaming individualsindividuals

Failure to discover resident pathogensFailure to discover resident pathogens Failure to identify error trapsFailure to identify error traps Management having its eye on the Management having its eye on the

wrong ballwrong ball A blame culture and a reporting culture A blame culture and a reporting culture

cannot co-existcannot co-exist

The journey

Westrum’s classification of Westrum’s classification of three types of safety culturethree types of safety culture

PathologicalPathological BureaucraticBureaucratic GenerativeGenerative

Main differences lie in the way organisationstreat safety-related information. Some deny it,

others welcome it.The journey

N

Thinking in causal series Thinking in causal series rather than causal networksrather than causal networks

Unaware of side-effectsUnaware of side-effectsThe journey

A self-perpetuating cycleA self-perpetuating cycle

BlameBlame

DenialDenialPursuit ofPursuit of

‘‘excellence’excellence’

The journey

A health warningA health warning

No organisation is entirely free of VSSNo organisation is entirely free of VSS Deeply rooted in human psychologyDeeply rooted in human psychology Need to be constantly on the look out for Need to be constantly on the look out for

the signs and symptomsthe signs and symptoms The ability to detect incipient indicators and The ability to detect incipient indicators and

the collective will to fight them are essential the collective will to fight them are essential prerequisites for effective risk managementprerequisites for effective risk management

The journey

A case study from the NHSA case study from the NHS

The incident: During a syringe change-over,a nurse incorrectly re-calibrated a syringe pumpdelivering a morphine infusion to a patient withstomach cancer, resulting in a fatal overdose.

The response: Institution suspended the nursepending an investigation. She was subsequentlygiven a formal written warning, reinstated andretrained in the use of syringe pumps.

The journey

Case study (cont.)Case study (cont.)

Incident investigation: Showed that a GrasebyMS26 syringe driver was being used. Whereasthis pump is calibrated in mm per hr, a secondwidely used pump, the Graseby MS16A, iscalibrated in mm per day. During the syringechange-over, the nurse applied the calibrationprinciples for the MS16A to a MS26 pump.

Early warning signs: Two similar errors hadrecently been reported. Both errors were detected before harm was done.

The journey

Case study (cont.)Case study (cont.)

Recommendation: Chief Pharmacist and twoconsultants wrote to management requestingthat a single pump be used throughout theTrust.

Management response: Suggestion rejectedbecause cost would make it impossiblefor the institution to stay within the budgetlimits set by the regional health authority

The journey

Recurrent system problemsRecurrent system problems

In all 3 cases, nurses had been working on In all 3 cases, nurses had been working on under-staffed wards. Sisters had under-staffed wards. Sisters had complained but mgt. accepted this as a complained but mgt. accepted this as a ‘sad fact of life’ and did not act.‘sad fact of life’ and did not act.

Key situational factors (equipment design, Key situational factors (equipment design, workload, etc.) were not thought relevant. workload, etc.) were not thought relevant. Sole focus on nurses involved: naming, Sole focus on nurses involved: naming, blaming, retraining.blaming, retraining.

The journey

Applying the ‘logic’ of VSSApplying the ‘logic’ of VSS

BlameBlame: There may be a few bad apples, : There may be a few bad apples, but the barrel is OKbut the barrel is OK

DenialDenial: If the barrel’s OK, then anyone : If the barrel’s OK, then anyone who says differently is either stupid or who says differently is either stupid or malicious—anyway, when did we last malicious—anyway, when did we last have a bad event?have a bad event?

Pursuit of ‘excellence’Pursuit of ‘excellence’: Now we’ve : Now we’ve sanctioned the bad apples and gagged sanctioned the bad apples and gagged the whistleblowers, we can focus on the whistleblowers, we can focus on meeting our financial targetsmeeting our financial targets

The journey

Culture: Two aspectsCulture: Two aspects

Something an organisation Something an organisation isis: shared : shared values and beliefs.values and beliefs.

Something an organisation Something an organisation hashas: : structures, practices, systems.structures, practices, systems.

Changing practices easier than changing Changing practices easier than changing values and beliefs.values and beliefs.

Engineering a safe culture

Building a safety cultureBuilding a safety culture

Practices and

structures

Beliefs andvalues

Using anddoing

Thinking and

believing

Building a safe culture

Can a safe culture be Can a safe culture be socially engineered?socially engineered?

Up to a point, YES:Up to a point, YES:• By creating a safety information system that

collects, analyses and disseminates the knowledge gained from incidents, near misses and other ‘free lessons’: A REPORTING CULTURE.

• To do this, however, we need the trust of the workforce: A JUST CULTURE.

Building a safe culture

Building a just cultureBuilding a just culture

A ‘no blame’ culture is neither feasible nor A ‘no blame’ culture is neither feasible nor desirable.desirable.

Some unsafe acts deserve sanctions.Some unsafe acts deserve sanctions. A ‘just’ culture depends on: A ‘just’ culture depends on:

• the trust of the workforce• knowing and agreeing the difference between

acceptable and unacceptable behaviour.

Building a safe culture

Can the law help?Can the law help?

NegligenceNegligence:: involves bringing about a involves bringing about a bad consequence that a ‘reasonable bad consequence that a ‘reasonable and prudent person’ would have and prudent person’ would have foreseen and avoided. Actions do not foreseen and avoided. Actions do not need to be intended. Mainly an issue for need to be intended. Mainly an issue for civil law.civil law.

RecklessnessRecklessness:: involves taking a involves taking a deliberate and unjustifiable risk. Mainly deliberate and unjustifiable risk. Mainly an issue for criminal law.an issue for criminal law.

Building a safe culture

The behavioural rangeThe behavioural range

SabotageSubstance abuse

Reckless violations, etc.

System-induced violations‘Honest’ errors

System-induced errorsetc.

Culpable Blameless

10% 90%

Building a safe culture

Diminishing culpability

Passsubstitution

test?

Deficienciesin training &selection orinexperience?

NO

Possiblenegligent

error

NO

System-induced

error

YES

YESWere the

actionsas intended?

Were the consequencesas intended?

Sabotage, malevolentdamage,

suicide, etc.

YES

YES

NO

NO

Unauthorisedsubstance?

Medicalcondition?

Substanceabuse without

mitigation

Substanceabuse withmitigation

NO YES

YES

NO

Blamelesserror

History of unsafe

acts?

YES NO

Blamelesserror butcorrectivetraining or

counsellingindicated

Knowinglyviolating

safe operatingprocedures?

Were proceduresavailable, workable

intelligible andcorrect?

Possiblerecklessviolation

System-inducedviolation

YES

YES

NO

NO

10% 90%

Decision tree

Building a safe culture

Building a reporting Building a reporting cultureculture

Qualified indemnity against sanctions.Qualified indemnity against sanctions. Confidentiality and/or de-identification.Confidentiality and/or de-identification. Separation of data collection from Separation of data collection from

disciplinary proceedings.disciplinary proceedings. Rapid, useful and intelligible feedback.Rapid, useful and intelligible feedback. Ease of making reportEase of making report

Building a safe culture

Single vs. double-loopSingle vs. double-looporganisational learningorganisational learning

from event reportsfrom event reports

Assumptions

Actions

Actual results

Results gap

Desired results

Single-looplearning

Double-looplearning

Building a safe culture

Four stages of learningFour stages of learning

Denyproblems

Boundedknow-how

LOCAL

ComplyWith rules

Fixsymptoms

CONTROL

Benchmarkthe best

Acceptdiffering

views

OPEN

Take asystems

view

Challengeassumptions

DEEPLEARNING

ReactiveComponentsInputsSingle-loop

ProactiveSystemsProcessesDouble-loop

Building a safe culture

Collective mindfulnessCollective mindfulness

A continuing awareness of the possibility of A continuing awareness of the possibility of human, technical and/or systemic failure.human, technical and/or systemic failure.

Expect that errors will be made and train Expect that errors will be made and train personnel to anticipate & recover them.personnel to anticipate & recover them.

Work hard to create a reporting culture & Work hard to create a reporting culture & make the most out of limited event data.make the most out of limited event data.

Generalise rather than localise failures.Generalise rather than localise failures. Brainstorm novel ways in which system could Brainstorm novel ways in which system could

fail.fail.

Building a safe culture

ConclusionsConclusions

The keys to a safe culture are intelligent The keys to a safe culture are intelligent wariness and knowing where the ‘edge’ is.wariness and knowing where the ‘edge’ is.

This requires:This requires:• An effective safety information system• The trust of the workforce• All hinge critically on a JUST CULTURE

Culture is crucial because it alone can have a Culture is crucial because it alone can have a uniform effect (for good or ill) upon the uniform effect (for good or ill) upon the system’s many and varied defences.system’s many and varied defences.