This document discusses a case involving a patient who received incompatible blood products during treatment for injuries from a car accident and later died. A root cause analysis found the nurse was pressured into administering the wrong blood by a surgeon during a busy period in the emergency department. The document then outlines considerations for addressing accountability and promoting a culture of safety, including defining disruptive behavior, just culture principles, and tools for evaluating safety culture such as leadership rounds. It provides example scripts and guidelines for conducting leadership rounds to openly discuss safety issues with frontline staff.

1. CULTURE OF
SAFETY
DR. MOHAMED MOSAAD HASAN
MD, MPH, CPHQ, CPPS, GBSS

2. Consider a Case
• You are a medical leader and receive a
call.
• A 25-year-old was transported to your
emergency department (ED) following a
road traffic accident.
• Your team identified multiple orthopedic
injuries and intra-abdominal bleeding,
requiring multiple transfusions.

3. Consider a Case
• While cleaning up, a team member
identified that the patient received 2
incompatible units of PRBC.
• Patient developed multisystem failure
and died.
• Uncertain if the transfusion error
contributed.
• The nurse who administered the
incompatible units is experienced.

4. Consider a Case
The ED was busy.
• Policy directs personnel to confirm two
identifiers before administering blood
products.
• After a “near miss” a year earlier, all ED
and operating room (OR) personnel were
retrained.

5. Consider a Case
• Quality and risk teams will review
records and schedule interviews.
• Policy directs a root cause analysis
(RCA) to be attended by involved
personnel.
• Other thoughts:
“I wonder what has been shared with
the family.”
You also think about your team—
nurses, physicians, or others—who
are involved

6. Safety Culture Definition
The safety culture of an organization is
the product of individual and group
values, attitudes, perceptions,
competencies, and patterns of
behavior that determine the
commitment to, and the style and
proficiency of, an organization’s health
and safety management.

7. related JCI Standards
• Standard GLD.13
Hospital leadership creates and
supports a culture of safety
program throughout the hospital.
• Standard GLD.13.1
Hospital leadership implements,
monitors, and takes action to
improve the program for a culture
of safety throughout the hospital.

8. Elements that promote success
1. Clear leadership commitment
2. Articulated goals
3. Changes in work patterns to create
teams that communicate and participate
in decision making
4. Elimination of unnecessary variation
5. Measures for tracking progress and
providing feedback
6. Stepwise, graduated interventions for
personnel exhibiting non-teamwork-
promoting (disruptive) behavior

9. Foundational elements
Four foundational elements:
• Shared values and goals
• Effective leadership
• Teamwork
• Safety culture
All affirm and mutually reinforce to
make health care safer

10. Shared values and goals for team
members
Credo
• I make those I serve my highest priority.
• I communicate effectively.
• I conduct myself professionally.
• I respect privacy and confidentiality.
• I have a sense of ownership.
• I am committed to my colleagues.

11. Effective Leadership
• Authority derives from their organization role,
policy directives, and hospital and medical staff
bylaws.
• Leaders understand mission and credo.
• Leaders establish (and follow) processes that
are transparent and data driven.
• Leaders understand their own accountability.
• Leaders will not “blink.”

12. Features of patient safety
culture program
• acknowledgment of the high-risk nature of
a hospital’s activities.
• an environment in which individuals are
able to report errors or near misses
without fear of reprimand or punishment;

13. Features of patient safety
culture program (Continued)
• encouragement of collaboration across
ranks and disciplines to seek solutions to
patient safety problems;
• organizational commitment of resources,
such as staff time, education, a safe
method for reporting issues

14. Just culture
• Balancing safety and accountability.
• The single greatest impediment to error
prevention in the medical industry “that we
punish people for the medical mistakes”.

16. Just culture
• 3 basics:
1. It doesn’t reduce the personal accountability and
discipline. It emphasizes the learning from the errors
and near misses to reduce errors in the future.
2. The greatest error not to report a mistake. Thereby
prevent learning.
3. All in the organization to serve as safety advocates.
Both providers and consumers will feel safe and
supported when they report medical errors, near
misses and voice concerns about patient safety.
It has zero tolerance for reckless behavior.

17. Behaviors
• Human error – inadvertent action: doing other than what
should have been done.
Manage through change in processes, procedures and
training.
• At risk behavior: behavioral choice that increase risk
where risk is not recognized or is believed to be justified.
Manage through increase awareness, and providing
incentives for healthy behaviors and disincentives for
risky behaviors.
• Reckless behavior: consciously disregard substantial and
unjustifiable risk.
Manage through Remedial and punitive action.

18. Reckless behaviors
• failure to follow hand-hygiene guidelines,
• Not performing the time-out before
surgery,
• or not marking the surgical

19. Zero Tolerance to Reckless
Behavior

20. Red rules
• cannot be broken
• few in number
• easy to remember
• associated only with processes that can cause
serious harm to employees, customers, or the product
line.
• must be followed exactly as specified except in rare or
urgent situations.
• Every worker, regardless of rank or experience in the
company, is expected to stop the work or production
line if the red rule is violated.

21. REASON’s “Unsafe Acts” Algorithm
• Did the team member intend to cause
harm?
• Did the team member come to work
impaired?
• Did the team member knowingly and
unreasonably increase risk?
• Would another team member in the same
situation act in a similar manner?

22. REASON’s “Unsafe Acts” Algorithm
Problem Level Of Intervention
Single Unprofessional
Incidents
Informal “Cup Of Coffee”
Intervention
Apparent Pattern Awareness Intervention
Pattern Persists Guided Intervention By
The Authority
Still Disciplinary Intervention

23. Patient Complaints
• “Dr. ___ is either too busy or
scatterbrained to read my files or is
dangerously neglectful.... I fear for my
safety and for her other patients....”
• “Dr. __ inserted a drain and walked out of
the room. After a while another MD
removed the drain and explained it wasn’t
even in the cyst.”

25. Back to the case
The RCA revealed:
• The incompatible units were intended for a
second victim.
• During the frenzy of activity, a nurse was
dispatched for trauma blood.
• By chance, he pulled two units intended
for another patient (E-admitting system did
not “talk” to lab system).

26. Back to the case
• As the nurse approached patient’s bedside, he
came under a barrage of expletives from
Surgeon X about getting the #@*&%! blood in.
• Nurse asserted, “I tried once to state I was
following procedure but felt pressured to do as
ordered.”
• Another team member—an RN—recognized the
high-risk situation but reflected, “I just didn’t
speak up.”

27. But What about The Human
Accountability

28. You Meet with Nurse 2
System needs:
The observer:
• Recognized a problem (colleague under
verbal assault) but did not speak up or get
help.
• No evidence of intended harm…no history
of unsafe acts.... You believe others might
have behaved similarly.

29. You Meet with Nurse 2
• However, by not speaking up, Nurse 2
increased the probability of risk.
• You follow up this isolated incident with an
informal cup of coffee conversation.

30. Principles for Informal
Conversation
Your role:
• To report an event
• To let the colleague know that the
behavior/action was noticed (surveillance)
• To avoid embarrassment/humiliation.
• Know message and “stay on message.”
• Allow the individual to be a professional.

31. You Meet with Nurse 1
• Came under verbal assault by Surgeon X.
• Reason’s Unsafe Acts Algorithm: Did not
intend...no prior history.... The nurse
acknowledges violating a policy.
• You believe a Level 1 “Awareness” feedback
would be appropriate to allow the nurse, as a
professional, to reflect on what happened.
• Goal is to provide feedback in a way designed to
protect other patients and to protect the well-
being of your team.

32. Awareness Guiding Principle
How to have the conversation:
• Review whatever “data” or story you have.
• Seek colleague's view (anticipate potential responses).
• Invite colleague to take time to identify potential ways to
address issue(s).
• Express appreciation if possible; acknowledge
contributions to organization; however…
• Explain that you will follow up….
• Document the conversation.

33. You Meet with Nurse 1
• You affirm that Nurse 1 is a valued team member.
• You review the results of the RCA.
• Ask Nurse 1 to reflect on the issues….
• Nurse 1 asks for assertiveness coaching as is concerned
that he allowed another team member to intimidate him.

35. Definition of Disruptive Behavior
• Disruptive behavior includes, but is not limited
to, words or actions that:
• Prevent or interfere w/an individual’s or group’s
work, or ability to achieve intended outcomes
(e.g., intentionally ignoring questions or not
returning phone calls or pages related to matters
involving patient care, or publicly criticizing other
members of the team or the institution).

36. Definition of Disruptive Behavior
• Create, or have the potential to create, an
intimidating, hostile, offensive, or potentially
unsafe work environment (e.g., verbal abuse,
sexual or other harassment, threatening or
intimidating words, or words reasonably
interpreted as threatening or intimidating).
• Threaten personal or group safety, aggressive
or violent physical action

37. Consequences of Disruptive
Behavior

38. Failure to Address Disruptive
Behavior
• Team members may adopt disruptive person’s
negative mood/anger (Dimberg & Ohman, 1996)
• Lessened trust among team members can lead
to lessened task performance (always
monitoring disruptive person)... affects quality
and patient safety (Lewicki & Bunker, 1995;
Wageman, 2000)
• Withdrawal (Schroeder et al, 2003; Pearson &
Porath, 2005)

39. Prior to Meeting with the
Surgeon
• Review results of RCA
• Review other performance/behavior data:
 mal claims
 An apparent pattern on non-teamwork promoting
(disruptive) behavior directed toward patient and
staff
• You previously spoke with Surgeon X about
complaints from coworkers and patients.
• You find it concerning that Surgeon X failed to
self-correct after previous (awareness) feedback.

40. Guided Intervention
• Pattern, no improvement; or Singular
significant event
• Plan developed:
 Authority figure and individual co-develop a plan; or
 Authority figure develops and specifies plan
• Clearly defined consequences if plan not
followed or doesn’t work within defined time

41. Evaluation of Patient Safety Culture
• Hospital leadership evaluates the culture
on a regular basis using a variety of
methods, such as:
Leadership walk-Around: allows leaders to
visit, observe, listen and ask questions
that elicit information about events or near
misses, concerns about safety

42. Evaluation of Patient Safety
Culture
Team member reports:
• Incidents events, near misses, unprofessional
behavior, observed or suspected violations of
regulatory requirements (privacy, unethical or
improper conduct), harassment or discrimination
complaints, unsafe equipment and medications,
equipment/product recalls.

43. Evaluation of Patient Safety
Culture
• Safety culture surveys
• Unsolicited patient/family complaints
• Trigger tools (systematic review of patient
charts to find markers that can identify
harm)

44. Patient Safety Leadership
WalkRounds
Developed by IHI

45. Purpose
• ƒDemonstrate commitment to safety. ƒ
• Fuel culture for change pertaining to patient
safety. ƒ
• Provide opportunities for senior leaders to
learn about patient safety.
• Identify opportunities for improving safety.
• Establish lines of communication about
patient safety. ƒ
• Establish a plan for the rapid testing of
safety-based improvements.

46. Indicators
• Response rate to cultural survey of front-line
workers and managers (process measure).
• Number of errors reported per month from
voluntary reporting systems (outcome
measure).
• Number of safety-based changes made by
heads of departments per year
• Percent of changes in overall infection rate.

47. Ground Rules
• The time and place of the WalkRound
would not be announced before its
commencement.
• All information that is discussed during the
WalkRounds is strictly confidential, and
leaders shall reassure employees for that.

48. Who Should Conduct
WalkRounds
• Hospital Director,
• Medical Director,
• Nursing Director,
• CQI/ PS director/ head,
• Assistant Hospital Director.

49. How often?
• Hospital Leaders shall commit to conduct
Walkrounds at a minimum of once per
week with no cancellation.
• Postponement can be done from previous
scheduled date, but shall be conducted
within the same week.
• Every member shall do the WalkRounds
with other members or alone.

50. Where
• Patient care units ƒ
• Operating rooms ƒ
• Emergency Department ƒ
• Radiology Department ƒ
• Pharmacy
• ƒLaboratories

51. What format
• Conversation with the member and three
to five employees that can be structured in
various ways, including:
Hallway conversations ƒ
Individual conversations in succession

52. Script for WalkRounds
• Opening statement:
“We’re interested in focusing on the system and not
individuals (no names are necessary).”
• Questions to Ask
 “Can you think of any events in the past day or few
days that have resulted in prolonged
hospitalization for a patient?”
Examples:
Appointments made but missed
Miscommunications
Delayed or omitted medications

53. Script for WalkRounds
 Have there been any near misses that almost caused patient
harm but didn’t?”
• Examples:
 Selecting a drug dose from the medications cart or pharmacy
to administer to a patient and then realizing it’s incorrect.
 Incorrect orders by physicians or others caught by nurses or
other staff.
 “Have there been any incidents lately that you can think of
where a patient was harmed?
 Examples: Infections.
 Surgical complications

54. Script for WalkRounds
 “What aspects of the environment are likely to lead to the next
patient harm?”
• Examples:
 Consider all aspects of admission, hospital stay, and discharge
 Consider movement within the hospital
 Consider communication
 Consider informatics and computer issues.
 “Is there anything we could do to prevent the next adverse event?”
• Examples:
 What information would be helpful to you? Consider alterations in
the interaction between clinicians. Consider teamwork
 Consider environment and workflow

55. Script for WalkRounds
 “Can you think of a way in which the system or your
environment fails you on a consistent basis?”
• Examples:
 Not enough information available.
 Requirements that don’t make sense
 Requirements that are unnecessarily time-consuming “What
specific intervention from leadership would make the work you
do safer for patients?”
• Examples:
 Organize interdisciplinary groups to evaluate a specific
problem.
 Assist in changing the attitude of a particular group. Facilitate
interaction between two specific groups.

56. Script for WalkRounds
 “What would make the WalkRounds™ more effective?”
• Examples:
 Informal conversations in the hallway instead of organized
conversations
 Individual conversations instead of group discussions Ensure
free time to discuss issues
 “How are we actively promoting a blame-free culture and
working on the development of a blame-free reporting policy?”
• Examples:
 We do not penalize individuals for inadvertent errors.
 The institution grants immunity to individuals who report
adverse events in a timely fashion.

57. Script for WalkRounds
• Closing Comment:
“We’re going to work on the information
you’ve given us. In return, we would like
you to tell two other people you work with
about the concepts we’ve discussed in this
conversation.”

58. CAN WE MEASURE THE
CULTURE OF SAFETY?

60. Thank You