SCCM Resource Library-Learning From Missteps: How to Apply Lessons From Error Into Practice

Video Transcription

Hello. Thank you very much for attending this session. Today we are going to talk about learning from missteps, how to apply lessons from error into practice. My name is Tina  Sifra and I'll be your moderator for this session. I'm currently an associate professor in the Division of Critical Care Medicine at the University of Iowa Carver College  of Medicine. I'm very happy to welcome you to this session. Today our objectives would be to identify important lessons in adverse events and medical errors, to assess methods  for limiting blame in root cause analysis in adverse events, and to assess methods for applying important lessons in adverse events and medical errors. Our speaker today is Dr.  Kyle Rader. Today Dr. Rader is going to talk about root cause analysis and how we can make it so that it will not be an imposition, and also how to make positive changes for the  future in our ICUs. Dr. Rader is currently Section Chief of Pediatric Intensive Care and Fellowship Director for the Division of Pediatric Critical Care at Duke. He is also  a Physician Quality Officer for Duke University Health System and Medical Director of the Duke Center for Healthcare Safety and Quality. Dr. Rader is a recognized expert in patient  safety, particularly in the realm of teamwork and communication, safety culture, and healthcare worker well-being. Welcome, Dr. Rader, and we hope you enjoy this session.  Hello, everyone. My name is Kyle Rader. I am the Section Chief for Pediatric Intensive Care at Duke Children's, and I'm also the Medical Director for the Duke Center for Healthcare  Safety and Quality, which is a large part of the reason that I was invited to speak. So thank you to SECM for inviting me to talk today about how do you make positive changes  for the future, especially looking at quality efforts and in the setting of errors. So my disclosures today, I have no significant disclosures. My wife and I each do some consulting  work here, you can see, for McKesson and for Illumina, but neither of those are relevant to the talk today. So as we think about in the setting of errors and how do we improve  quality, and specifically how do we improve safety culture, I just want to review quickly  Pascal's evolution of safety culture. So how do we move people from unmindful up to generative?  And so what do these things mean? So if we think about unmindful, this is where people just show up and do the work, and people are chronically complacent. Obviously, this is  not where we want to be. Unfortunately, reactive is where a lot of hospitals live, which is  they recognize safety is important, and every time there's an accident, then they do things  to try to address that. But it's always reactive to something that's already happened bad. Fortunately, in the era of a greater focus on safety, more hospitals are moving into  the systematic space where people are putting things into place to manage hazards, and really  trying to think ahead and plan for those hazards that might be there, moving forward more to a proactive culture where we're starting to anticipate those events that may occur and  prevent problems before they get there. But ultimately, how can we get to the generative stage? And that's as we think about how do you make things better for the future? Developing  an organizational culture that is genetically wired to produce safety, and this is something we're thinking about all the time, and we have all of our employees and all of our staff  working towards this. So really what we're talking about here is organizational learning.  How do we learn from our mistakes as an organization and have this constant learning such that  we get better every day and that we can adapt in real time as new things come online? Because  we can try to predict as much as we can things that may happen in the future, but realistically,  the environment that we work in, particularly in the ICU, but even in healthcare in general, is fast-paced, and there's always going to be unanticipated things that come along.  In one way, we can think about this as those who don't learn from their mistakes are doomed to repeat them, and we're good at learning as individuals. So if I put my hand on a hot  stove, I learned that quickly I don't want to do that again. But how do we learn as an organization from one person who may learn that event? And the thing this comes back  to, and the most important thing where it starts with, is psychological safety. So what is psychological safety? Psychological safety is the ability to speak up with concerns or  with ideas without the fear of negative consequences to either your self-image, to your status on the team, and to your career. The second two bullets you may also hear of called as  professional safety, the thought that I can speak up, I can raise concerns, I can disagree with someone, and it's not going to affect my ability to progress in my career. But even  broadly, more broadly, we talk about this as psychological safety, which is keeping that self-image safe and feeling like you can speak up without those negative impacts.  And ultimately, when you have psychological safety, it's this shared belief that it's okay on this team or in this group to take risks and to be innovative or to think of  really creative ideas and understand that your teammates are going to trust you for that. And you know what? If it's a bad idea, that's okay. They've still got your back.  And so this is what we want to build on our teams that is going to set the groundwork for that organizational learning that we spoke of and how we can get better every day.  So recently, in 2014, there was a systematic review looking back at some of the published literature about what are those factors that are associated with speaking up. And so some  of the things that were really recognized was leadership that's supportive of voicing concerns. Not surprisingly, if leaders are asking people to speak up with their concerns  and are responding well when those concerns are brought up, it's more likely that people will speak up. Similarly, there needs to be a trust in leader and teammates, and that's  often based on how do people react when I do speak up? Am I belittled? Am I made fun of? Am I blown off? Or do people listen to my concerns and potentially make changes on  that or at least address why the change is not made when I raise a concern or a new idea? Another thing that makes people more likely to speak up is if there's significant risk  of harm. If they don't see the event that's happened as likely to cause harm to patients or likely to cause harm to the team, people are less likely to speak up. But if they see  the real risk, not surprisingly, they're more likely to speak up. The other thing though is it starts to get into culture. So as a team, do we have a consistent focus on safety  concerns? And is it something we talk about? Is it something we try to address routinely?  And what is the sense of professional responsibility of the team members so that they feel it's  important to speak up and they feel like they have this responsibility to the patients? So again, not surprisingly, when they feel that strong sense of responsibility and when  the team is constantly focused on concerns, people are more likely to speak up there. And then finally, this gets back into how do people respond when I speak up, is if  I have the sense that I speak up with a concern, it will actually lead to a change or lead to some sort of action, then it's likely that I'm going to speak up again. And that's that  positive feedback loop that we want to develop. So if we take all of these, I want to put  four main themes around this. And this is the ideas of giving team members voice, developing trust on the team, having a high level of accountability, and then overall developing  a culture where it's safe to speak up. So you'll notice, you know, I started with psychological safety, but accountability is also so important to this concept of organizational  learning and how do we get better. If we don't have psychological safety, nor do we have accountability, if both of those are low, then we live in this apathy zone. People  show up, but they just go through the motions. It's not my problem. They ignore safety concerns  because it's not on their list and no one really cares. If we build high psychological safety but do not focus on accountability as well, then we live in this comfort zone.  And so, you know, status quo is accepted because, yeah, we make mistakes, but, you know, it happens. It's all good. It's okay. And we still don't make changes and we don't learn  from our mistakes and we're still set up for mistakes to happen again. Where we often see that we live in the ICU and in hospitals is this anxiety zone. So high accountability,  we have a high sense of responsibility, but it's not safe to speak up. So people are afraid  to speak up because they worry that they're going to get, you know, damaged to their professional  career. They're going to, people are going to see them differently for making a mistake. And so they kind of keep their head down. We don't talk about errors and safety issues  are often covered up. And once again, that sets us to have the same mistakes happen over and over again. So where we want to be is this learning zone. So high psychological  safety, we're going to talk about mistakes. We're going to talk about errors. We're going to come up with good ideas, but we also have this accountability that we know we need to  do better and we are always focused on doing better. So that's really where we want to live. So from here, I want to get into some different tools that we can use to help our  teams live in that learning zone. The first of those is teaching team members critical language. So providing them the words to speak up. So, yeah, I know I have a concern. I want  to speak up, but how do I speak up to that attending? How do I speak up to that really senior nurse? And so give them that word. So the term we use for that is critical language.  The common terminology that's used nationally for this is the cuss language. I'm concerned.  I'm uncomfortable. This is a safety issue. We need to stop. And so you can see the escalation in language. If you say you're concerned and someone doesn't respond, then you escalate  to that next sentence of I'm uncomfortable. And this is what is taught in the TeamSTEPPS program that has been adopted by AHRQ, which has been adopted by the American Hospital  Association. In our own pediatric ICU, when we started looking at critical language, you could walk up to me or most of our patients and say, yeah, hey, I'm concerned about room  two. And my response would be, yeah, I'm concerned about room two as well, because all of our patients are sick and unstable. So we need something to stand out a little  bit more. And you can see the badge here that we developed for our team of I need clarity. And I need clarity allows any team member to speak up with that phrase. And it's code  language to say we need to stop and think, because we may be about to make a mistake.  It's language that stands out in normal conversation. It's not a phrase that we would use out in  different settings. And it also allows us to say, I am concerned, but it allows us to say in front of a family member or a patient to say, I need some clarity before we continue.  And so that's worked pretty well for us. And at the end of the day, it's you're advocating  not who is right, but what's the right thing to do for the patient. And so just as important  getting a language is how people respond when they hear that. And so if someone hears this speak up of I need clarity, the response is, OK, let's stop. Let's make sure we're all  on the same page before we continue. And let me thank you for speaking up. So after we introduced this language into the Duke IQ, we saw significant improvements  and you can see different aspects of our culture. People felt more comfortable speaking up. They felt like they had greater ability to discuss errors. They felt like physicians  and nurses were working well together, working better together. And at the end of the day, the most important thing, I would feel safe being treated in this unit. You can see we  saw a significant jump there going from mid-50s up to almost 80% of people saying that they would feel safe being treated in this unit. So just introducing that language, you can  see started to help people speak up with concerns and ideas, making sure they're on the same page before we move forward with care. Some other things that we've done at Duke are  to recognize people when they do speak up. And so we've instituted the Good Catch Award. It's a pin that goes on the badge and you'll see these throughout the hospital, a little  silver pin with that hand on it. And really what we do is we recognize people who raise  concerns and particularly if they raise concerns before a patient was harmed. And so two examples I can have here is a nurse was setting up an operating room before surgery and she  kept bumping into things and realized, wait, if we're setting up for a right-sided knee  procedure, why is all the equipment set up for left-sided? And so she spoke up and fortunately  found a discrepancy in the paperwork where one place it was listed as a left-sided surgery,  one place listed as a right-sided surgery and was able to clarify that before a wrong-side  surgery occurred. Similarly, a food services worker who had been delivering meals to patients walked into one patient room. They had seen the patient that morning. They brought in  dinner for the same patient and noticed the patient was not the same and there had been a real change and raised this concern to the nurse and ultimately allowed the patient  to get the therapy they needed. So when these types of events happen, we surprise people at staff meetings or other things and award them with this award. And you can see there  one of our health system leaders, Dr. Formoska, presenting awards to that nurse anesthetist, presenting that pin that they can wear and really recognize that we're celebrating the  fact that people are speaking up. And specifically, we often try to recognize those times when someone spoke up and it led to a broader change so we can, again, give them feedback  on, you know, that was great that you caught it for this event, but these are some changes that we're making to help our care be safer throughout the entire health system.  We also have worked on trying to teach our leaders to show humble inquiry, going out into units and into areas to say, you know, tell me about how things are working here  and really asking people and understanding, yes, I'm in a leadership role, but these front-line  staff are our experts in the work that they do every day. And they can really teach us so much. And one of the phrases I love when a leader can go into an area and say, teach  me why you do it this way. It's not questioning that it's wrong that someone does something  a certain way, that they really want to learn. And so this, again, helps support that idea  of organizational learning across organizations. It strengthens the voice of that front-line  staff. When we talked about one of the things important for people speaking up is feeling like their voice matters. And if you have leaders going out and asking your opinion,  asking things that could be done better, asking, you know, your expertise on how you do a certain  job is certainly something that you can imagine helps people feel like their voice matters. We also teach transparency about fallibility. Leaders admit that they have their own, you  know, their own fallibility, their own ability to make mistakes. And it strengthens the idea  of safety as a team effort and a team sport. And we need to all be in this together, looking out for each other. And once a leader has opened up about some things that they can  improve on, it's more likely that their team members will also open up. Another really key skill or a nice skill to use is the idea of role activation. And so  this works well during humble inquiry. It also works well during debriefing, which we'll talk about in a bit. But the idea of role activation is in a group, turning to someone  to ask what their thoughts are, but in that moment, highlighting the expertise that they  bring in. So, Stephen, as a respiratory therapist, what do you think about this? And what, in that moment, what I've done is I've called out Stephen by name, saying that I want to  hear his thoughts. But I've recognized that he, as a respiratory therapist, has a certain skill set and a certain knowledge base and expertise that I don't have. And so I really  want to hear from that. And so once again, it strengthens the fact that he brings something to the table and I want to hear his voice. And then finally, the tool that we teach is  this idea of positive rounding with feedback. And so you may have heard the concept of leader walk around. We have leaders go out in the unit, walk around, ask about what's going  well here, what can be done better. As we focused on positive roundings, what we found is asking about three things that are going well, and one thing that we could do better.  Once again, leaders are going out, talking to frontline staff. And then after that rounding event, they come back and say, this is what I heard. This is the feedback I heard from  the staff. So I hear you and here are some changes that we're going to work on, some changes that we're going to make right away, and maybe some changes that we're going to  work on down the road that we can't affect yet, but we're going to work towards that goal. So we went out and asked people across Duke Health, 33,000 employees, who had been  exposed to this type of positive rounding experience. And what we saw is that people in blue were the ones who answered that, yes, I participated in this positive rounding and  received feedback from my leader about what they heard. People in gray had not experienced that. And you can see we looked into multiple culture domains, things like the learning  environment. And again, that's organizational learning. How well do we learn from errors, learn from our mistakes? What do I think about my local leadership? Teamwork climate, how  well do we work together as a team? Safety climate, how safe and student we treated here? We looked at both burnout, my own personal burnout and burnout climate. What's the burnout  of these people around me? And even work-life balance. And you can see there's big differences here in people in blue who've been exposed to positive rounds and participated in that  versus the people in gray who've never experienced that. And for samples this size, about two points difference in any of these scales would be statistically significant.  And here we're talking about 30 point differences for learning environment, local leadership, for teamwork climate. So really massive differences based on people's experience  with something like leader walk-arounds specifically with that positive rounding strategy.  And this gets into the idea of feedback. So yes, we want to hear your voice, but we also need to build accountability. And one of the ways to do that is using feedback.  So how does feedback support speaking up? So it tells someone how to be better. It also helps  drive that idea of we all want to be better. And everyone says they want feedback, but it's  interesting to see how closely tied to speaking up this is. So this is actually a survey data  we commonly collect from different health systems throughout the country and we help analyze.  Two specific questions I'm going to focus on when we do culture analysis. So one of those is,  I receive appropriate feedback about my performance in a Likert scale. I disagree, I agree.  And then another question is, in this clinical area, it's difficult to speak up if I perceive  a problem with patient care. So how likely are people to speak up? So we ask these two questions  and how do they correlate and work well together? So what we see, and I apologize this data is a  little bit old. However, I can say that more current data shows the same pattern that I'm  going to talk about. So you can see this data is actually from the Michigan Keystone Collaborative  and looking at 71 ICUs throughout the state of Michigan. And what we saw is that in 2004,  people who said, yes, I get feedback on my job were also more likely to say, I'm more likely to speak up. Same thing held true in 2006. So we see that pattern hold true over  time and I'll show you some more data in a minute that supports that. However, just because I was  comfortable speaking up in 2004 doesn't necessarily mean that I'm going to be comfortable speaking up  two years later in 2006, nor is it likely speaking up in 2004 to have any significant correlation to  getting feedback in 2006. Now let me flip that around. If I get feedback in 2004, what does that  mean for the future? What we saw is we saw a good correlation between getting feedback in 2004  versus speaking up and getting feedback in 2006. So in this way, and I apologize the graph's a  little complicated, but what we're seeing is that feedback now predicts speaking up in the future  and getting feedback now also predicts speaking up in the moment. So feedback really is the driver  for helping people speak up when they have concerns. And it's not only showing that I'm  concerned about helping you be better at your work by giving you feedback, but it's also helping  build that sense of accountability. So this is data, as I mentioned, from ICUs that were in the  Michigan Keystone Collaborative. What about ORs that were in the same collaborative? And what  you see is it's the exact same pattern. Getting feedback now, and this is now we've moved to 2008,  2011, the same pattern shows up repeatedly. That's feedback... getting feedback now is predictive of speaking up now. It's also predictive of speaking up in the future.  So how do we build a culture of feedback? And I mentioned debriefing already. So debriefing is a  chance for the team to come together and practice real-time learning, that idea of organizational  learning. You develop in that moment these group habits of speaking up with concerns, giving feedback to each other in a safe environment. And what we know is that when  teams and ICU teams practice debriefing and giving feedback to each other, it's more likely  that they'll give feedback to each other outside of the debriefing. And it's also more likely that  they'll speak up outside of the debriefing. And at the end of the day, you end up crowdsourcing  solutions and coming up with better plans and better things to really help improve care.  So some data that supports this. So this is data from the Rhode Island Quality Institute,  again, looking at ICUs across their collaborative. They saw that ICUs that routinely did not use debriefing saw culture scores lift over time in the wrong direction,  and they saw either increases or no improvements in their hospital-acquired conditions. Whereas  if you looked at ICUs debriefs, you saw the opposite pattern. You saw that culture score  continued to improve over time, and that CLABSI rates and fat reduction, other things like that,  showed consistent improvement over time. So again, this idea of bringing people together, talking about how we can do things better. The thing I encourage is debrief not only when  something goes bad, but debrief after things go well also, recognizing that we can learn  from something that goes well, and the things that we want to reinforce in a positive way, in the same way that we can learn when something goes poorly. So try to schedule  debriefs routinely. For example, we debrief after every code. We debrief after every information  to try to learn from that and learn what we need to reinforce. So at the end of the day,  we can build psychological safety, and we can give people that voice and then show that their voice  has an impact. Then we empower our staff, and that is going to lead to group problem solving, and that is going to lead to organizational learning and constantly getting better.  And so one last bit of data I'll show you is we, you know, trying to use that combination of psychological safety and accountability to drive empowerment and innovation. So at Duke,  in the last year, a couple of years, we have been working on the new quality system, and we've  gone into specific units to work on three big things. One is real-time problem solving,  where we're trying to empower individuals at the front line to solve problems in the moment and not  have to go through committees and things. We're using tiered huddles to keep this focus on safety  issues every day and bringing the team together to talk about safety issues and to have that group  problem solving. And then finally, we're sharing learning across units so that we can continuously  get better. And when we're using a lot of the tools that I've talked about, whether it be critical language, whether it be debriefing, whether it be, you know, giving feedback,  and this leaders with humble inquiry. And what we've seen is the first wave of the units that  went into this new quality system using some of these lean principles, some of these organizational  principles in terms of leadership. What we saw is the units that have participated in this, our wave one units in light blue, compared to the control units in gray,  saw significant improvements in our recent culture survey in empowerment, belonging, career development, you know, the ability for people to see that their career is advancing.  Safety, even things like work-life balance and well-being have improved for those units that  are participating. So we can see how that shared understanding and that shared problem solving  that's happening at the moment has really big impacts that are going to have lasting impacts into the future. So to pull this home, the things I want you all to remember is that  psychological safety is going to be the big starting point for driving organizational learning.  It has to be paired with accountability, that local leaders can have a huge impact on this. And so some of the things to really focus on humble inquiry, potentially with leader  walk-arounds or using positive grounding specifically, and the importance of giving feedback to people, to the people you work with, and particularly for leaders to give feedback  to their staff. A couple other tools that you can use to build psychological safety that you can use  to help drive that organizational learning and the ability to get better is critical language, giving people the language that they need to speak up. Again, we use I Need Clarity,  but I'll also remind you of the CUSS language that's used in many places with TeamSTEPPS. And then the other tool is debriefing, the idea of getting the team together  to practice those chances to speak out and mentor together. And what we've seen is that can have such positive results not only from the debriefs themselves,  but moving forward and outside of the debriefs, how teams will act together. And using things during debriefs, like that same Humble Inquiry, like role activation  and asking individuals to bring their expertise into the conversation.  Just one other thing I'll highlight as I'm wrapping up is a few more resources. So we've got quite a few resources on the hsqdukehealth.org site,  which is the Center for Healthcare Safety and Quality website and specifically I'll drive you to the Bite Size Team Training, which has quick videos around debriefing,  around critical language that you may find useful in either your own work or be able to share with others to kind of help develop this content.  Today, I'm gonna be talking about root cause analysis and how do we learn from errors when they happen? Obviously, root cause analysis is a huge topic.  When I went to my own training course, it was a three day long course with folks who do investigations for plane disasters and other major events like that. Obviously in 20 minutes,  we're gonna have a very limited scope, but hopefully I can give you some tools that you'll find useful as you think about learning from errors.  So quickly, I have no disclosures of notes. I do a little bit of consulting as does my wife. However, neither are relevant to the talk and what I'll be speaking to today.  So a few years ago, when I joined a new institution, I went to find out when M&M was scheduled after an event happened and I wanted to talk about it with folks  and see what we could learn from it. And I came to find out that M&M was canceled. They had completely canceled their morbidity mortality conferences.  And as I looked into that a little bit more, what I found out is this was their view of how the morbidity mortality conferences ran. It was often run much more as an inquisition,  which the title of the talk is nobody wants an inquisition, but it was a situation where people felt like they were brought up in front of a panel.  Every question or motive was questioned and scrutinized. And it really made it hard to dig into why did the error happen? Because it was about the person  and it was not about the actual events. And functionally what happened is they stopped having these conferences where they could learn from errors.  And that meant they were not learning from their errors. And that set them up to have the same mistakes happen over and over again.  So what they had lost was the idea of just culture. And some of you may be familiar with just culture. I'm going to dive into it really quickly  for those of you who may not be aware of this concept. But at the very base, just culture starts with an assumption. And that assumption is that nobody shows up in the morning  claiming to harm a patient. Let's hope that the people we work with really come to try to do the right thing. Now, that being said, we are human and errors will happen.  So just culture also brings in three other rules and what we talk about the duties. And the overarching duty of our work is to not cause harm.  And so all of us who show up at work in a hospital or in a healthcare setting have that overarching duty to not cause harm.  But there's two other duties that we also have to consider. We have to consider the duty to follow procedures and policies and rules that may be in place.  And we also have a duty to produce a specific outcome. And that's hopefully the best outcome for our patients. It may be survival, it may be getting off the ventilator,  any other thing like that. And sometimes these duties come in conflict with each other. We may be trying to do the right thing for the patient  and that means bending the rules or breaking a procedure. And so anytime we look at a mistake or an error or something that has caused harm,  we have to look at it in context of all three of these duties and what was going on in that moment. The other thing we look at is specifically  the behavior of the individual at play. So we have three behaviors that we like to look at. The first of that is human error. The second is at-risk behavior,  and the third is reckless behavior. And which of these categories does that behavior fall into? So human error, let me just put this in terms of maybe driving a car.  Recently, they installed a new stop sign in my neighborhood, and it's a street I've driven down 1,000 times. And it can be very easy that one day when I'm not used to the stop sign  that I drive through the stop sign because I don't see it and I'm not used to it being there. And that is a simple human mistake that we all can make mistakes like that.  Now, what about at-risk behavior? How is that a little bit different? So maybe now I have my pregnant wife in the car and she is in labor and I am worried  she's going to deliver any minute and I want to get her to the hospital. And I pull up to a red light, I stop, I look both ways,  I don't see anyone coming, and so I run that red light. I am breaking up a policy, I'm breaking the procedure, I'm breaking the rules because I'm trying  to do the right thing for my patient, in this case, my wife. And so in that moment, I'm showing at-risk behavior, but I'm trying to do the right thing.  Reckless behavior is if I was to drive through that same stop light without stopping because I'm drunk driving, and that is not acceptable. And so we think about these behaviors  and how people are acting, and that's going to help drive when we really try to look at the systems that we're supporting people in the moment,  when we try to coach people in at-risk behaviors of I understand you were trying to do the right thing, but that wasn't the right way to do it, or when it's truly reckless behavior  that we then save those times for punishment.  So one way to help sort that out is the idea of the substitution rule. So is it human error or is it some other behavior? And so here we have a group of people,  group of healthcare workers in the center, highlighted in red, you've got someone who made an error that ultimately caused patient harm. To decide if this is truly human error  or a systems issue versus a person problem, what we can do is we can substitute someone else in that same situation, under the same circumstances, the same decision,  would that other person make the same choices? If that other person would make the same choices or could have made the same error, then it's not a problem with the person,  it's a problem with how the system is built around it, it's a problem with the process, and in those cases, we don't want to punish that person.  So again, this is that idea of just culture. And once you lose just culture, it's really hard to learn from mistakes.  So if we can start with just culture, then what we need to do is understand the error. And so as we understand the error, we move into the idea of data collection and evaluation.  After we get that data collected and start to evaluate it, then we move into more of the analysis phase. And so, yes, I'm gonna talk about root cause analysis today,  but root cause analysis is a very detailed analysis of an error that may not be the only way to do that. Root cause analysis are required for joint commission sentinel events,  and there's a host of defined events that require, again, that full root cause analysis. But realistically, these are such in-depth analysis that requires such tools and skills  that it's best reserved for patient safety professionals. Now, any of you may be called at some point to participate in the root cause analysis,  and get to experience it maybe from the other side as well. Now, that being said, before we finish today, I do wanna talk to you about one other form of analysis  called learning from defects. And this is a simpler form of root cause analysis that you can use in your own units, in your own work settings,  that can help your team learn from errors and develop an action plan that ultimately can help fix things so you don't have the same error happen again.  So the first step is data collection. And there's five main forms of data that we wanna think about after an error. And that's people, position, electronic data,  physical data or physical items, and finally, the paper record. Now, when we talk about position here, we're talking about where were things,  where were people at the time of the error or when something went wrong. As we move from left to right, we see that the reliability and the durability  of that data, of that information increases. So the least reliable source of data is people.  And unfortunately, as people's memory can change over time, they cannot remember a few events. They may have had tunnel vision at the time of the event  and not realize what was going on around them. Similarly, things can be moved immediately after an event. And so position is that next, the least reliable form.  Whereas if you have physical items that were involved in the events or if you have a paper record, that's gonna be your most durable and reliable source of data.  So knowing that people who are involved are gonna be potentially your weakest form of data, interviewing participants for data collection is really important.  And first and foremost, you want to collect different perspectives and you want to try to find multiple people who may have been involved in the event  and people who would have had different perspectives at the time of the event. And so not only may they have seen different things, they may have known different things,  noticed different things, and hearing from them and hearing their different perspectives and different skillsets is gonna be very important.  Similarly, you want to ask open-ended questions. You want them to tell you the story of what they saw and what they thought was going on. What were they thinking in that moment?  Have them teach you why they made the choice that they made. And after those open-ended questions is when you can clarify and collect detail. What you don't wanna do  is start with accusatory questions or leading questions. Because accusatory questions, again, going back to no one wants an inquisition, these people are probably on some degree  suffering from maybe a choice they made and they may be in some degree of moral distress. But once they feel like someone's accusing them, we all go into defensive mode  and we start to cover up our decisions or we start to not be as honest about the decisions because we don't wanna look back. Similarly, if we ask leading questions,  people tell you what they think you want to hear. And so they may not give you the most precise or accurate answer. So we want to take the information that they give,  take it from multiple people, and then put together the picture.  After we start to get that data, there's a host of tools that we can use to start to recreate the event as it happened. And one of those is looking just at a timeline.  What were the multiple events that may have led up to that adverse event or that mistake or that error that happened? And when did those events happen?  And this is a good visual demonstration of the events leading up, again, to the adverse event. And even to make this more detailed, what you could do is you can add logic gates  along that timeline. What were those times when a key decision was made that could have stopped this timeline from progressing or a chance to catch this before things went bad?  What were key decisions that were made that really did advance the timeline and progress things? And so that really helps, again, a visual demonstration of those key times  that ultimately contributed to the error.  We often will use process mapping as well to really lay out how do we reach the goal of what we want to do? What is the process that helped us get there?  And then we can look at where the process may have broken down that ultimately led to the error. And you can see here, this is a simple flowchart  where we start, we have decision points, we have different steps along the way. And as we map this out for an event, what we will do is we will make notes at each step,  at each decision point, and look at those key decision points that were made. So again, another visual representation that can help us really understand  what went into the decisions, what were the necessary steps that ultimately resulted in an adverse event.  We'll also use fishbone diagrams, or the formal name is Ishikawa diagrams. And what you can see here, the head of the fish is the outcome, the error that happened,  the ultimate thing that occurred. And along the way, the bones of the fish are going to be different potential causes or potential contributors to this.  And this is a brainstorming activity. There is no wrong answer. This is where you get people in a room and you want them to come up with any potential thing  that contributed to that negative outcome, to that error that happened. And then you try to group those contributors within certain categories. Were these people who were involved?  Was this the electronic medical record? IT issues that were involved? What about the environment? Was there something about the physical space that contributed?  And so again, this is meant to be an all-inclusive, come up with any idea you can. There's no wrong answer. And then we're going to take all of these potential contributors  and really focus in on what were the things that we really think contributed to the outcome.  So once we've started to understand those causes, what we'll see is we'll see causal factors, intermediate causes, and then we can look a little bit deeper  as what are the root causes. So the causal factors are the immediate performance gaps. The intermediate causes are the systems that are around the person making a decision  or performing an action. And then at the end of the day, the root causes generally are going to be the management systems and the organizational culture and the leadership  that evolves in that work area. So just an example, the patient receives the wrong med. We ask, why did the nurse give the wrong med? Well, the med was in the wrong drawer.  They grabbed the wrong medicine. And we could stop there, but that's not going to prevent that thing from happening again. As soon as the med gets put in the wrong drawer again,  we can have the same mistake again. So that's the causal factor, if you will. It's the initial performance gap. But let's look a little bit deeper  about what put the medicine in the wrong drawer. Maybe we can look at the delivery process. How are the meds delivered to the drawer and what is the process? So we can map that out.  How is staff trained as far as how they're going to deliver that med? Or even what's the design of the PCSIS that holds the medicines?  But if we look even a little bit deeper, what we may find is that when this new PCSIS was put in place and there was a new delivery process developed, we didn't really assess  what are the key things that we need to build in so that we're thinking about safety as medicines are delivered to individual units. And so maybe leadership failed to really assess  that process as they were implementing a new process. And maybe it was unclear who owns the process once it's developed. So again, the importance of how did leadership  really set this up to be safe? And stepping back to this root cause of how was the system designed and how did we build safety in the process  is ultimately what we'll need to address to make sure this same error doesn't happen again. Now, that being said, we may still find areas for improvement in the intermediate causes,  the delivery process, training of staff, PCSIS design, things like that. And so we may actually come out with multiple action items.  Another way that helps us dig down into this is the concept of five whys. And this is also used in lean management that some of you may be familiar with.  So yes, something happened, but why did it happen? And let's ask again, why did that happen? So as an example, my car ran out of gas. Why did that happen? I didn't fill it up.  That seems to be a simple answer. And that's a human error on my part. I didn't fill it up. But let's ask a little deeper. Why did I not fill it up? Well, the gauge was broken.  Okay, well, so I didn't know I needed to fill up. Why was the gauge broken? Well, it turns out that there was a recall notice that I didn't receive.  And so I didn't know that the gauge was gonna have an issue, but somewhere someone did. Why didn't I receive the recall notice?  There was a typo in the registered address of the dealer. And why was there a typo there? There's not a confirmation process for information entry.  And so we can look back multiple steps, again, ask why five times. Why did that happen? But why did that happen? And why did that, you know, and then go deeper  and find a place where if we can fix, again, an organizational culture thing or fix an upstream process that will help prevent the same type of event happening again in the future.  So once we really understand the process, we can develop what we call a cause and effect tree. And so, yes, a human error happened and it had negative impact on the patient.  That was the ultimate effect. That's not what we want. What were the causes that led to that? Obviously, the human error had to occur to begin with  for that human error with impact to happen. However, there was also a failure to catch. And you can see if we build a cause and effect tree,  we have our logic gates, our Boolean algebra with ands, and we're gonna add an or at the minute. And that then really helps us understand  what are all the conditions necessary to be in place for this negative outcome. And so the human error occurred and we did not catch that human error before it reached the patient.  Why didn't we catch it? Because we either did not detect it or we failed to prevent it to begin with. And so now we can look at the different aspects within detection and prevention  and that's potentially where we need to focus because human error should never be a root cause. Because at the end of the day, we're humans  and people are doing their best to do their work.  But we work in a very busy environment. We work in an environment where people are interrupted and fatigued. And so simple human error, we can never completely fix.  However, we can fix systems that support humans to make better choices.  Finally, we wanna classify and categorize the different root causes that may be present. And that's gonna help us not only understand the true drivers of safety in your unit  and in your organization, but it's gonna help us track events over time. Are we seeing one particular category of event that bubbles to the surface again and again?  And this is something we really need to look at. How is this designed and we need to improve? And again, that's gonna help focus our improvement efforts.  So we're not trying to just fix little one-offs throughout the entire organization, but there's one big effort that we need to focus on  that's gonna have a lasting and a large impact for other organization in terms of improving safety.  So that is kind of an overview of the big RCA and just a few tools that can be used. But that whole process can be quite detailed. And realistically, for most of the errors  that may happen in your unit, you're not gonna be able to perform a whole RCA. You're just not gonna have time in the busy work that you all have to do.  So this is a tool that you can use that's gonna be much easier for folks to use and can be done in a shorter period of time. So think of it as RCA-like,  this idea of learning from defects. A defect has happened, an error has happened, something, maybe it was even a near miss, but what can we learn from that  to make sure that same thing doesn't happen again? This can often be completed in about 45 minutes. And this is actually the model that our pediatric residency program has used  for their morbidity and mortality conferences for the last several years. And it's worked so well, we've rolled it out to all of the other departments  here at Duke to try to model this same use to be able to come up with the investigation of why an error happened and also coming up with action items of what we can fix.  It is still a systematic analysis of contributing factors. And in many ways, it is a different format of the fishbone diagram I showed you earlier, where you're trying to think  of all the potential contributing factors and then focusing in on one of the ones that made the biggest impact, had the biggest effect on the event. And this really works best  in interprofessional teams. So the same idea of when you're interviewing, you wanna get as many different perspectives as possible. If you're trying to really understand  what went wrong that led to an error, you need to have a lot of different perspectives and particularly different perspectives, not only from individuals,  but different perspectives in terms of their specialties and their expertise. So you want not only, if you just have a room of physicians, you're not gonna really get good answers.  You want physicians, nurses, and pharmacists, respiratory therapists, all the people who may understand and be involved in the process that led to the error.  So what we do is we write at the top, what happened, you know, the error that happened and we quickly review that. We may present a timeline of how it occurred.  We may even present something like a process map so that people can understand the error as it happened. And then we flip over to this table  and this table shows essentially a box for each category. And so what we ask is throughout the table, we ask people to come up with any ideas of things that may have contributed  either in a positive way or a negative way towards that error. So positive way, it's something that prevented, mitigated the error, prevented it from being worse,  prevented that impact from being worse. And in a negative way, this was something that directly contributed to the error. And again, having the different categories  laid out in front of us. What about human enduring, human factors? What about training and education? What about communication breakdown? This helps people think broadly  so we can be as inclusive as possible of potential contributors. And so what we'll do is we'll spend probably about anywhere between 15 and 20 minutes  brainstorming on any of the potential factors that may have contributed to the error as it happened. And then once we've got those on the board, we can look at which were the ones  that probably had the biggest impact. And then that will help us drive what are the potential action items we need to move forward with.  So again, this learning to defects tool works really well in a simple conference format  on the unit to just have a very broad overview of the different factors that may have contributed to an error.  So at the end of either an RCA or learning to defects, it's not complete unless you come up with an action plan because you're not going to fix anything without action plan.  You'll actually see the joint commission and other organizations now call it RCA square. So root cause analysis and action. You have to have that action plan.  Otherwise you're not really fixing anything.  As you think about action plans, it's necessary to think about the strength of actions. So that's great. You can put in a warning or alert or you can educate someone,  but that's a really weak strength of action and it's not going to last very long. Education is great for a few weeks, but then people fall back into their own habits.  However, if you can standardize a new process, if you can automate something or even add a forcing function such that it does not allow someone to do the wrong thing,  that's going to be a much stronger action and that's going to be how you achieve sustainability and preventing the same event from happening again.  You also want to look at high yield actions. What are the things that whatever group is working on this project or evaluating this error or trying to make it better,  what are the actions that they can do that are going to have the biggest impact? And as we think about that, just an example of how we may approach this,  you can't even do it mathematically and do it in a very objective way, but let's talk about action plans. So we had an error that happened and we came up with four potential actions  that we think might help. We think a new EHR system, a new electronic health record would fix everything and that would be great. We could also change patient flow to our work area.  We could change the way that nurses chart their data and that would be helpful in preventing that error. Or we could also develop a new order set.  So as we think about each of these, we want to look at the potential impact. How likely is it to fix it if we make this change?  And also, what is our ability to make that change? What's the potential to change? So yes, a new HR system would be great. That would have a huge impact,  but our ability to do that is pretty minimal. So we're going to give that as zero. What about changing patient flow? Yeah, we could probably do that  and it's got a reasonable potential, reasonable chance to change that and it would have some impact. So we're going to multiply those scores together and give it a six.  Same thing with nursing charting data. We could definitely change it, may not have a huge impact, that's going to be a 10. New order set, you could see that's going to give us  an overall score of 12. Now, this is a guideline. Just because new order set has the highest score of 12 doesn't mean absolutely that's the one you should do,  but we now have a visual drive that tells us what are our highest yield interventions. So let's look at a new order set in nursing charting  and figure out which of those we want to do.  All right, so the things I want you to remember is as you go into event analysis, model just culture. Realize that people are trying to do the right thing  and then we need to support them when human error happens because they often are experiencing guilt or what we call the second victim syndrome  and simply blaming something on human error is not going to fix the problem. And so we need to understand what happened and figure out how we can build systems  better to support that.  After you model just culture, you need to go beyond the causal factors and what are the really the root causes, what are the organizational factors,  the management systems that we can fix that are going to have a much broader impact in fixing the problem.  Use the tools that we talked about to understand that contributes to the error. Things like the fishbone diagram, timelines, process mapping to really understand that error.  And then at the end, whether you do a root cause analysis or learning from defects, you need strong action plans that are necessary for sustainability.  So think of the strengths of the actions that you choose and that's what's going to be necessary. So thanks everyone for your attention today. I hope you found this useful.  You can see on the right here, we have our websites, particularly the Center for Healthcare Safety and Quality has some good resources in this area  or you'll also find my contact information there. So please reach out to me if I can be helpful. Thank you very much.

Video Summary

In this video, Dr. Kyle Rader discusses the importance of learning from missteps in the medical field and how to apply those lessons into practice. He emphasizes the need for a just culture, where mistakes are seen as opportunities for improvement rather than occasions for blame. Dr. Rader introduces the concept of psychological safety, which allows for open communication and the ability to speak up without fear of negative consequences. He explores how to develop a culture of psychological safety by giving team members a voice, building trust, fostering accountability, and creating a safe space for speaking up. Dr. Rader also highlights the importance of feedback in supporting speaking up and driving organizational learning. He presents various tools, such as critical language, debriefing, and positive rounding, that can be used to build psychological safety and encourage a culture of continuous improvement. Additionally, Dr. Rader briefly discusses the root cause analysis (RCA) process and its role in understanding and learning from errors. He concludes by emphasizing the need for action plans to address identified issues and ensure sustained improvement. Overall, Dr. Rader provides insights and practical approaches for healthcare professionals to effectively learn from missteps and implement positive changes.

Asset Subtitle

Quality and Patient Safety, Administration, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Learning Objectives

Identify important lessons in adverse events and medical errors
Assess methods for limiting blame in root cause analysis in adverse events and medical errors
Assess methods for applying important lessons in adverse events and medical errors

Root Cause Analysis: Nobody Wants an Inquisition
Kyle Rehder

Making Positive Changes for the Future
Kyle Rehder

Meta Tag

Content Type Presentation

Knowledge Area Quality and Patient Safety

Knowledge Area Administration

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Learning Pathway Introduction to the ICU

Membership Level Select

Tag Communication

Tag Medical Legal Issues

Year 2021

Keywords

learning from missteps

just culture

psychological safety

open communication

feedback

continuous improvement

root cause analysis

action plans

healthcare professionals

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