My presentation at The 15th Annual NPSF Patient Safety Congress break-out session.

1. “A Paradigm Shift From Blame To Fair And Just Culture”
A Middle East Hospital Experience
Krishnan Sankaranarayanan MS, MBA, CPHQ
Senior Safety Officer- Tawam Hospital
Presented at the NPSF Patient Safety Congress
8-10 May 2013 New Orleans USA

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Disclosure
The presenter has nothing to disclose, nor has any
commercial interest with any of those information's
displayed in this presentation.

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About Tawam Hospital
• Tawam is a 466-bed tertiary care facility located in the garden city Al Ain in the
middle of the desert, and one among the largest healthcare facilities in the United
Arab Emirates.
• In 2006 the General Authority of Heath Services now called as the Abu Dhabi
Health Services Company PJSC (SEHA) entered in to a ten year affiliation contract
with Johns Hopkins Medicine.
• Tawam Hospital has current status with
• Joint Commission International Accreditation (2006; 2009; 2012),
• College of American Pathology (CAP; 2011) and
• American College of Graduate Medical Education- International (ACGME; Program
Accreditation)

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Items for discussion
• Ice breaker- Eric Cropp a pharmacist, the error that
sent him to prison (Video)
• Second Victim
• Comprehensive Unit-based Patient Safety program
• Understanding the Culture of Safety journey from a
Middle East perceptive
• Understanding how the concepts of leadership
engagement and learning from defects translated
in to the organization
• Celebrating Safety- The Best Catch Award

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Ice Breaker

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Aftermath of an error- Shame & Blame

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Common Response After An Error
The types of suffering are
• Increased anxiety about the future possibility of errors,
• Loss of confidence in the work they do,
• Some face difficulty sleeping,
• Concern about their reputation as a care giver
• Reduction in their sense of job satisfaction.
• Excellent clinicians may leave the profession prematurely
when involved in a preventable error.
Rossheim J. To err is human—even for medical workers. Healthcare monster. http://healthcare.monster.ca/8099_en-CA_pf.asp (accessed 21 Jan
2009).
Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J
Qual Patient Saf 2007;33:467–76.

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Medical error: the second victim..
The term second victim was initially coined by Wu in his
description of the impact of errors on professionals. The doctor
who makes the mistake needs help too.
In the aftermath of a mistake, it's important the doctor seek
support to deal with the consequences.
Albert W Wu associate professor
School of Hygiene and Public Health and School of Medicine, Johns
Hopkins University, Baltimore, MD

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Middle East: There no or lack of statistical evidence in this
region to showcase patient deaths happening due to medical
error

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This is what we see?

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The patients saw an average of 17.8 health
professionals during their hospitalization
How many health professionals does a patient see during an average hospital
stay? N Whitt, R Harvey, S Child
The patients saw an average of 17.8 health
professionals during their hospitalization

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Building a Culture of Safety

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Safety Culture comes from
High Reliability Organizations

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Definition- Culture of Safety
• Safety culture is the ways in which safety is managed in the
workplace, and often reflects "the attitudes, beliefs, perceptions
and values that employees share in relation to safety" (Cox and
Cox, 1991).
• 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. Organizations with a positive safety culture are
characterized by communications founded on mutual trust, by
shared perceptions of the importance of safety, and by confidence
in the efficacy of preventive measures. (AHRQ)
Source: Organising for Safety: Third Report of the ACSNI (Advisory Committee on the Safety of Nuclear
Installations) Study Group on Human Factors. Health and Safety Commission (of Great Britain).
Sudbury, England: HSE Books, 1993.

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Characteristics of Culture in safe organizations
• Commit to no harm
• Focus on systems not people
• Value Communication/teamwork
• Assertive communication
• Teamwork
• Situational awareness
• Accept responsibility for systems in which we work
• Recognize culture is local
• Seek to expose (not hide) defects
• Celebrate safety
• Workers viewed as heroes

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February
22, 2001, eighteen-month
old Josie King died from
medical errors at the
Johns Hopkins Hospital
Peter J. Pronovost, MD, PhD
is a practicing anesthesiologist and
critical care physician,
teacher, researcher, and
international patient safety leader.
Johns Hopkins Medicine
Comprehensive Unit-based Safety Program-(CUSP)

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Comprehensive Unit-based Safety Program (CUSP)
6-step safety program
Step 1: Safety Attitude Questionnaire (SAQ)
Step 2:Staff education on the Science of Safety
Step 3: 2-item Staff Safety Survey
▪ Please describe how you think the next patient in your unit/clinical area will be
harmed?
▪ Please describe what you think can be done to prevent or minimize this harm?
Step 4: Executive Walk Rounds
Step 5:
a) Learning from defects
b) Improving teamwork and communication
Step 6 : Resurvey staff about Safety Culture (annually)

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How we started at Tawam?
• January-08 Created the Patient Safety dept.
recruited 4 patient safety officers and a medication
safety officer.
• February-08 Leadership training on Patient Safety
• April-08 Comprehensive Unit based Safety Program
Roll-Out.
• 2008- ICU, NNU, Peds Onc (Pilot Units)
• 2011- Medical 1 & 2, Surgical 1& 2, Daycase, PICU
• 2012- OBGYN
• 2013- OR & ED

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Challenges faced at Tawam
• Employees hail from 60 different nations
• Hierarchies between providers
• A culture that isn’t accustomed to acknowledging
medical errors.
• Tendency for poor communication and teamwork
that lead to adverse events.
• Tawam had a history of, “you made a mistake, and
you’re terminated.”

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CUSP -Pilot Test
Executive Leaders Adopted Units
• These units were selected partly due to their high
risk & high volume nature and closed medical staff.
The units were selected in part due to;-
their high-risk, high-volume nature and use of closed medical staffs.

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CUSP is a leadership driven &
Partnership driven program

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Stakeholders & Team

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Baseline assessment-
Safety Attitudes Questionnaire
Culture of Safety Survey- Domains
1.Teamwork Climate
2.Safety Climate
3.Job Satisfaction
4.Stress Recognition
5.Working Conditions
6.Perceptions of Hospital Management
7.Perceptions of Unit Management

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Dependent Variables of SAQ
• The primary dependent variables -teamwork
climate and safety climate scale scores.
• These primary dependent variables were chosen
because they are important in preventing patient
harm.
• The rest of them are secondary dependent
variables.
Sexton J.B., et al.: The Safety Attitudes Questionnaire: Psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res
6(44):Apr. 3, 2006.
Timmel J, Kent PS, Holzmueller CG, Paine L, Schulick RD, Pronovost PJ. Impact of the Comprehensive Unit-Based Safety Program (CUSP) on safety
culture in a surgical inpatient unit. Jt Comm J Qual Patient Saf 2010;36(6):252-260.

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Location Year
Targeted
staff
Surveys
Administered
Survey
Returned
Survey
response
rate
Phase 1 CUSP Pilot Units 2008 199 199 199 100%
Phase 2 In-patient areas 2010 1600 1476 1450 98%
Phase 3
Out-Patient & satellite
locations
Qtr 4
2011 805 497 483 60%
Total 2604 2172 2132
82% of staff in patient care areas have participated in the overall 3 phases of SAQ Survey.
81% overall response rate in all the 3 phases of SAQ Survey.
Safety Attitude Questionnaire-(SAQ)

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2008 SAQ Phase-1 (CUSP Pilot Units)
0%
20%
40%
60%
80%
100%
Teamwork Safety Job
Satisfaction
Stress
Recognition
Perceptions
of Hospital
Management
Perceptions
of Unit
Management
Working
Conditions
Average%Positive
Domain
SAQ Results 2008
ICU
Pediatric Oncology
NNU

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2 question survey: Pilot Units- 2008
Please describe how you think the next patient in your unit/clinical area will be harmed.
Please describe what you think can be done to prevent or minimize this harm.
0%
5%
10%
15%
20%
25%
30%
Communication
& Teamwork
Staffing Medication
Errors
Infection Control Policies &
Procedures
Education Equipment Others
Areas of concern
2-item Staff Safety Survey
ICU N=93
NICU N=73
Peds Onc N=39

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2010 SAQ Phase-2
(All In-patient Units- & CUSP Pilot Units Re-survey)

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SAQ- Resurvey of CUSP pilot units

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2011 SAQ Phase-3 (Out-patient Units)

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2011 SAQ Phase-3
primary dependent
variables

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SAQ- Action Plan
• De-briefer tool- least positive and most positive
scores.
• Unit staff identified specific areas of concern and
developed action plans for improvement.
• Rolled out CUSP in more units.

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CUSP Expansion
Leadership Assigned to Twelve CUSP units

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Peds Oncology - CUSP Meeting
Peds Oncology - CUSP Meeting
NICU- CUSP Meeting
ICU- CUSP Meeting

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CUSP Executive walk rounds
Steve Talking to the House Keeping staff
COO ICU CUSP Executive Walk rounds CFO Peds Oncology - CUSP Executive Walk rounds
CEO NNU- CUSP Executive Walk rounds

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Executive walk rounds- Challenges
• Leaders asked frontline staff their safety
concerns
• Instead of bringing up safety issues, staff
typically talked about the protocols they
followed to prevent harm.
• Nowadays they ask pointed question:- For
instance
• “Have you had any problems with pharmacy recently on
medications prepared for the ICU?”
• How is your communication with the Physicians??

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Culture linkages to Clinical, Operational & other
Outcomes
•Wrong Site Surgeries
•Decubitus Ulcers
•Delays
•Bloodstream
Infections
•Post-Op Sepsis
•Post-Op Infections
•Post-Op Bleeding
•PE/DVT
•RN Turnover
•Absenteeism
•VAP
•Burnout
•Unit size
•Communication
breakdowns
•Familiarity
•Spirituality
•Most validated:
Qual. Saf. Health
Care
2005;14;364-366

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ICU -VAP CLABSI & CAUTI
17.3
5.5
2.3
4.2
5.3
2 1.8
0
2
4
6
8
10
12
14
16
18
20
2006 2007 2008 2009 2010 2011 2012
Infections/1000devicedays
Ventilator Associated Pneumonia -ICU
Ventilator Associated Pneumonia -…
0.5
0.7
0.8
0
0.2
0.4
0.6
0.8
1
2010 2011 2012
Infections/1000devicedays
Central Line Associated Blood Stream
Infections - ICU
Rate/1000 device days
91
96
88
89
90
91
92
93
94
95
96
97
2011 2012
ICU Average Rate for VAP Bundle Compliance
86
93
82
84
86
88
90
92
94
2011 2012
ICU Average Rate for CVL Bundle Compliance

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0
1
0.3
0
0.2
0.4
0.6
0.8
1
1.2
2009 2010 2011
Infections/1000devicedays
year
Ventilator Associated Pneumonia -NICU
6 5.9
3.6
0
1
2
3
4
5
6
7
2009 2010 2011
Infections/1000devicedays
year
Central Line Associated Blood Stream
Infections -NICU
NICU -VAP & CLABSI

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2.04
1.55
4.07
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
2010 2011 2012
CABSI/1000devicedays
year
Central Line Associated Blood Stream Infections - Peds Oncology
Peds Oncology- CLABSI

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CLABSI Free Days
ICU
• 323 CLABSI free days until 25th Dec 2012
• Recounting -42 CLABSI free days until 5th February.
• Recounting -23 CLABSI free days until 28th Feb.
NNU-183 days until 28th Feb.
PICU- 115 days until 28th Feb.

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ICU CLABSI Free Days
CUSP Team with the ICU Executive - COO

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NNU CLABSI Free Days

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“I Watch The Line”- Campaign
• To increase staff awareness
• To ensure staff active involvement
• To ensure conscientious implementation
ICU NNU PICU

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Error Prevention
“Learning from Defects”
“Smart people learn from their
own mistakes, wise people learn
from other's mistakes.”

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Formula 1 Pit stop

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Formula 1 Pit stop
• Takes six to twelve seconds in duration.
• Every pit stop is filmed and monitored by
human factor experts
• Errors are scored in five levels
• Highest score goes to the smallest
error, because people are unaware of it.

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Aviation-Sterile cockpit rule
• Prohibits crew member performance of non-
essential duties or activities while the aircraft is
involved in taxi, takeoff, landing, and all other flight
operations conducted below 10,000 feet, except
cruise flight.
• Prohibits the personal use of a personal wireless
communications device or laptop computer while a
flight crew member is at duty station during all
ground operations

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Learning from Defects- Tawam
Created Safety Event Analysis Teams in
each CUSP unit.
Identified a team of believers
Team identified defects from Patient Safety Net
(PSN)
Implemented systems changes to reduce the
probability of recurring.
At least one defect was investigated each
month.

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System changes due to PSN’s on Narcotic
medication error
Verbal order carried out against policy for Narcotic
medication. (Fentanyl Patch)
Analyzed usage of each Narcotic and Controlled medication (for
the previous six months).
Determined Critical/emergency need of each n drug.
List of Narcotic and Controlled medications were reduced to half.
ICU physicians and nurses informed about the changes.
Review the usage every 3 months.

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Team members involved being felicitated
In the picture:
Iyad Mahmoud; Jainy Mathew; Lynn Petrie; Krish and Dr. Said Abuhasna

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System changes due to PSN’s on Pressure Ulcers
9 PU’s reported between Oct 2011 &Mar 2012
Joint investigation conducted Wound care nurse and wound care
link nurse.
Developed Nursing care plan.
Conducted 0ne to one education.
Involved Respiratory Therapists.
BIPAP gel masks will be used to prevent PU’s related to BIPAP.

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Team members involved being felicitated -
Wound care & RT
In the picture:
Priya Padmanabhan; Stephanie Woodworth; Lynn Petrie; Krish and Dr. Said Abuhasna

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When errors occur one of the three things happen
• It can cause people to become champions
Or
• It can cause people to leave the profession
prematurely
Or
• It can make people go in to a shell and completely
feel withdrawn- Disengaged.

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Medication Error Story-1(Peds Oncology CUSP)
Double check for
expiration date not
done properly
First Nurse proceeded
to administer the
vaccine without taking
the tablet PC to the
patient bed side
Vaccine Injected and
asked second Nurse to
chart in Cerner on his
behalf
Second Nurse baffled after seeing
the expiration date and the
missing expiration date in the
label
Error reached
the patient but
did not cause
harm
Expired vaccine
arrived from
Pharmacy
SWISS CHEESE MODEL

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Medication Error Story-2 (Peds Oncology CUSP)
Chemotherapy
Written by MD.
Vincristine
doxorubicin
And
l_aspargenes
Checked
according
To the protocol
Then faxed
to pharmacy
Prepared by
Pharmacy
Medication
Received from
Pharmacy,
Checked with
Another
Chemotherapy
Competent
Nurse
VCR
DOXO
L-Asp
Two medication
taken to
patient room
VCR
and
DOXO
And
Emla cream
L-Asp returned to
fridge
602013-4-29

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Medication Error Story-3 (Day Surgery CUSP)
What
Happened
• Remicade a non formulary was administered to the patient (order was
in paper)
• Premedication of antihistamine, paracetamol was ordered in CERNER
which was not communicated to the nurse
• The patient developed allergic reactions
What Next
• Investigation revealed that there was no set protocols or guidelines
• Break down in communication & information transfer
Action
• Guidelines, protocols and checklist were developed
• No incidents since then

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Implication of the errors
• The staff came open and reported the incidents
• Since CUSP was in place it helped institute a Fair
and Just Culture
• Investigation of the incidents, examined the
processes and not just people.
• The three nurses have now become advocates of
patient safety by sharing their experiences.

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Distribution of Harmful Events by Care Units, 2010
0 20 40 60 80 100 120 140 160 180 200
Medical 1
Naima Pharmacy
OR
Paeds Medical
Medical 2
Paeds Oncology
113
128
139
152
163
183
13
0
29
10
11
3
No. Harmful event
No. of Reported Event

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Medication Error Story-4-(Second Victim)
A nurse inadvertently administered a chemotherapy drug to a wrong patient.
The patient was ok and the error was openly disclosed to the family. It was a
clear case of the nurse not adhering to the principles of five rights and
independently double checking the high alert medication. A case of
negligence!!!
The nurse had no previous history of such an error, was emotionally so
distressed that the nurse could no more work in the unit. The patient family
members did realize that the error was not intentional and did support the
nurse who was devastated due to the incident.
Despite the fact that CUSP was existence in that unit for over four
years, there was no established mechanism to console the nurse. Due to the
increased anxiety about the future possibility of errors and loss of confidence
in ones own work, tragically the nurse chose to leave the specialty
prematurely, the one that the nurse had been working for over fifteen years.

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Impact of CUSP on the staff
CUSP can turn ordinary people in to
CHAMPIONS

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Best Catch Award program
Celebrating Safety – Viewing workers as
heroes
• Instituted in 2009 for the best near miss caught.
• Now in the fifth year of implementation.
• Provided opportunity for staff to proactively
identify and implement risk reduction strategies.
• 2010, 2011 & 2012 Best Catch awards went to
CUSP units.

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Best Catch Award 2010
Peds Oncology CUSP
Synopsis :
Chemotherapy IFOSFAMIDE per protocol is for four doses, and it was written for 5 days.
The fifth dose arrived , nurse checked protocol and prevented.
Systemic change :
A copy of the protocol in pharmacy and patient chart to double check and prevent errors.
Prevented excess dose of
Chemotherapy medication

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Best Catch Award 2011
ICU CUSP
Rhian Evans
Associate Nurse Manager - ICU
Tawam Hospital
Synopsis :
Prevented family from approaching patient on ventilator with hot burning coal in patient room.
Coal was extinguished safely. Resulted in system and policy changes.
Prevented cauterization and
accidental fire in the ICU

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Best Catch Award 2012
Peds Oncology CUSP
Synopsis
The physician had ordered Metototrexate IT for this patient. In OR the mother of the
patient told the nurse that the patient should receive Cytarabin IT, not Metotrexate. The
Physician had prescribed the wrong drug.
Prevented administration of wrong
chemotherapy medication

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Up coming book called “Patients Come Second” by Paul
Spiegelman & Britt Berrett
The book talks about caring for those (employees), who care for
the patients. Employee engagement, getting them excited about
providing good service to patients, which reflects on patient
loyalty and good outcomes.

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Discussion-The End Game

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Healthcare Needs Robust System
• A cooperative effort between government agencies
(regulatory authorities), Health Policy makers and
industry to lead improvements in safety.
• Healthcare needs an independent body modeled after
the National Transportation and Safety Board (NTSB).
National Medical Safety Board (NMSBSM)
http://psoservices.net/nmsb/

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Positive things happening in the Middle East region
United Arab Emirates-
SEHA one of the largest healthcare systems in the region has
established the PSN reporting tool in all its business entities.
DHA Implements New Patient Safety System called “Aman”
based on a global healthcare safety system called DATIX
Saudi Arabia- Is now asking all hospitals, government
or private, to use online reporting for any serious
medical error.
Qatar- HMC has introduced real time incident reporting
system at its chain of hospitals.

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Culture of Safety is a journey
• It takes as long as 5 years to develop a
culture of safety that is felt throughout
an organization. (Ginsburg et.al 2005)
• Need
Patience, Perseverance, Commitment &
Engagement.

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Resources-websites
http://www.iom.edu/
http://www.npsf.org/
http://www.ihi.org/explore/patientsafety/pages/default.aspx
http://www.hopkinsmedicine.org/armstrong_institute/
http://www.josieking.org/
https://www.patientsafetygroup.org/main/index.cfm
http://www.pso.ahrq.gov/
http://www.patientsafety.gov/
http://www.safetyleaders.org/

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References
• Kohn LT, Corrigan JM, Donaldson MS, editors. To Err Is Human: Building a Safer Health System.
Washington: National Academy Press; 1999
• How many health professionals does a patient see during an average hospital stay? N Whitt, R Harvey, S
Child
• Sexton J.B., et al.: The Safety Attitudes Questionnaire: Psychometric properties, benchmarking data, and
emerging research. BMC Health Serv Res 6(44):Apr. 3, 2006.
• Pronovost PJ, Holzmueller CG, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual
and Saf 2006 32(2):102-8.
• Ginsburg, L., P. G. Norton, A. Casebeer, and S. Lewis. 2005. ‘‘An Educational Intervention to Enhance Nurse
Leaders’ Perceptions of Patient Safety Culture.’’ Health Services Research 40 (4): 997–1020.
• Timmel J, Kent PS, Holzmueller CG, Paine L, Schulick RD, Pronovost PJ. Impact of the Comprehensive Unit-
Based Safety Program (CUSP) on safety culture in a surgical inpatient unit. Jt Comm J Qual Patient Saf
2010;36(6):252-260.
• Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians in
the United States and Canada. Jt Comm J Qual Patient Saf 2007;33:467–76
• Rossheim J. To err is human—even for medical workers. Healthcare monster.
http://healthcare.monster.ca/8099_en-CA_pf.asp (accessed 21 Jan 2009).
• Wu AW (2000). "Medical error: the second victim. The doctor who makes the mistake needs help too".
BMJ 320 (7237): 726–7.
• How many health professionals does a patient see during an average hospital stay? N Whitt, R Harvey, S
Child
• Ginsburg, L., P. G. Norton, A. Casebeer, and S. Lewis. 2005. ‘‘An Educational Intervention to Enhance Nurse
Leaders’ Perceptions of Patient Safety Culture.’’ Health Services Research 40 (4): 997–1020.

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Thank You
Patient Safety Top Priority
Patient Safety Everyone's Responsibility
Contacts:
ksankara@tawamhospital.ae
+971 -50-9211649