ORGANIZATIONAL CULTURE AND MEDICATION SAFETY Nicole Mollenkopf MacLaughlin, PharmD, BCPS Medication Safety Officer for Pediatrics The Johns Hopkins Hospital [email protected] 410-502-6048Objectives  Compare and Contrast a punitive culture, blame-free culture and just culture  Provide pharmacy practice examples of human error, at-risk and reckless behavior  Describe the appropriate management response to the three types of manageable behaviors (human error, at-risk and reckless)  List at least three “safe behaviors” all pharmacists should exhibitOrganizational Culture  What is meant by culture ….  Dictionary definition: the set of shared attitudes, values, goals, and practices. Webster’s English DictionaryOrganizational Culture  What is meant by culture ….  Simple definition: “the way we do things around here” Sexton, et al.Why do we care about culture?  Healthcare is high risk!  Intrinsically complex  Highly hazardous  Relies heavily on actions of humans  Combines variety of technologies that are capable of both healing and harming  Culture influences patient safety  Culture can cause an organization to be vulnerable, rather than resilient, to patient harmVulnerable or Resilient?  One indication of an organization’s culture is the way the organization pursues and responds to errors ….Types of Culture Pathologic Bureaucratic Generative Don’t want to know May not find out Actively seek it Messengers (i.e. whistle blowers are shot) Messengers are listened to if they arrive Messengers are trained and rewarded Failure is punished or concealed Failure leads to local repair Failure leads to far-reaching reforms New ideas are discouraged New ideas often present problems New ideas are welcomed Westrum, et al.Generative Culture = Safety Culture  Commitment to create and support safe systems  Atmosphere where individuals feel free to identify and describe known safety problems  Rigorous analysis and correction of errors and near misses  Respect for individuals and complexity of the organization and systems  Minimize hierarchies  Just culture (atmosphere of trust and accountability) Szekendi, MK, et al. Jt Comm J Qual Patient Safe. 2010; 36(1):3-9.Focus on System Focus on Person Actions following an error…Traditional mindset in medicine…  Blame, shame, and train mentality  Fix the person and the problem goes away  But what happens next time … and there will eventually be a next time, right?Punitive Culture  “Name, shame and blame”  Focused on the person  Perfection expected  Severity of discipline determined by severity of undesirable outcome  Get rid of the “bad apples”  Apparent fix is fast and easy  Emotionally satisfying ISMP Medication Safety Alert. 2006; 11(18)1-2.Punitive Culture Weed out the “bad practitioners”http://www.youtube.com/watch?v=iru56ZO9tKcEmily Jerry / Eric Cropp Case On August 14, 2009, Eric Cropp was charged criminally and sentenced to:  6 months in prison  6 months of home confinement with electronic monitoring  400 hours of community service  $5,000 fine  Payment of court costsPunitive Culture  Weakness: Fear of reporting, no learning, no improvements!  Creates a defensive, knee-jerk environment  Increases stress level of employees and decreases employee job satisfaction  Encourages people to hide mistakes  System is not fixed and may be further weakenedThe single greatest impediment to error prevention is that “we punish people for making mistakes.” Dr. Lucian Leape Professor, Harvard School of Public Health Testimony before Congress on Health Care Quality ImprovementBlame-Free Culture  “Amnesty for all”  Acknowledges human fallibility  Perfection viewed as impossible  Recognizes that error is rooted in weaknesses of the system  Weakness:  Fails to account for individual’s contribution to the system – safe or unsafe behavioral choices?  Too Lax, inconsistent or no consequences for unsafe choices ISMP Medication Safety Alert. 2006; 11(18)1-2.System vs. People System PeopleSystem People System vs. PeopleJust Culture Safe Design Safe Choices Systems PeopleJust Culture  Balances the system and the individual  Good system design  Safe behavioral choices  Creates “shared accountability”  Challenging to implement and maintain ISMP Medication Safety Alert. 2006; 11(18)1-2.Design Safe Systems  Create reliable systems for people to work in:  Anticipate human failure  Capture errors before they become critical  Permit recovery when consequences reach the patient  Guide staff down the “good decision-making” path www.justculture.orgManage Staffs’ Behavioral Choices  Understand three manageable behaviors  Learn how to coach staff around safe behavioral choices  Recognize when remedial and disciplinary actions are necessary www.justculture.orgThree Manageable Behaviors Human Error • Inadvertent action • Slip, lapse, mistake At-Risk Behavior (“Drifting”) • Behavioral choice; Human nature • Risk is not recognized or is mistakenly believed to be justified Reckless Behavior • Behavioral choice • Conscious disregard towards a substantial and unjustifiable riskHuman Error  Human error  Mistakes, slips or lapses … can happen to the best of us!  No intent, don’t choose to make the error www.justculture.org; ISMP Medication Safety Alert. 2006; 11(19)1-2.28Mistake Proofing 29Human Error “We cannot change the human condition, but we can change the conditions under which humans work.” James Reason Professor Emeritus University of ManchesterHuman Error  Manage through *design* changes of:  Processes  Systems  Environment  How about discipline? www.justculture.org; ISMP Medication Safety Alert. 2006; 11(19)1-2.33 ISMP 2011 Institute for Safe Medication Practices34Look Alike/Sound Alike (LASA) MedsBar-Code Enabled Workflow 37Managing Human Error  Questions we should be asking  Did the employee make the correct behavioral choices in their task?  Is the employee effectively managing their own performance shaping factors?  If yes: Console the individual; fix the system • Stress • Fatigue • Environment • Lighting • Noise • Distractions • CommunicationAt-Risk Behavior  At-risk behavior 