Back ground Tawam hospital faced many of the same barriers to patient safety present in hospitals elsewhere. The Leadership realized that the best way to enhance patient safety is to build a Culture of Safety at the hospital and hence has been implementing the Johns Hopkins Comprehensive Unit based Safety Program (CUSP). CUSP started as a pilot project in 2008 and now being implemented in ten units. Prior to implementation the leadership decided to measure staff perception of safety using evidence based tool. Method The Safety Attitudes Questionnaire (SAQ) was administered to all Tawam Hospital staff in three phases understand staff perception of safety. SAQ measures culture along 7 dimensions. The survey results are graded against percentage positive responses. Results A comparison of the SAQ’s pre & post CUSP implementation. ICU and Pediatric Oncology had six domains in the danger zone. NNU had four domains in the danger zone. 2010 & 2011 SAQ survey, the overall hospital score on all the domain scores were in the danger zone. 20 clinical locations in 2010 and 7 clinical locations in 2011 had less than 60% scores in the primary dependent variables. Conclusion SAQ results were disseminated department wise in the presence of a hospital Senior Executive. The unit staff selected one or two areas of concern and developed action plans for improvement. CUSP was rolled out in Six more units. Safety Analysis Teams have been established in the CUSP pilot units to analyze and learn from defects.

1. Establishing Safety Event Analysis Team
(SEAT)
“turned ordinary people in to champions”
Presented at The Johns Hopkins Fifth Annual Patient Safety Summit
Baltimore -June 6, 2014
Presented By
Krishnan Sankaranayanan MS, MBA, CPHQ, FASHRM
Senior Safety Officer / Tawam Hospital

2. Disclosure
The presenter has nothing to disclose, nor has any
commercial interest with any of those information's
displayed in this presentation.
2014/7/13 2

3. 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)
2014/7/13 3

4. Discussion items
• Non-punitive approach to error reporting.
• Culture of safety survey scores and event
reporting linkages.
• Creating a process to help frontline staff
report incidents and learn lessons out of it.

5. Summit Theme-"In Pursuit of High Reliability
HRO principles
• Aligns with all the five principles of high
reliability
1. Sensitivity to operations
2. Reluctance to simplify
3. Preoccupation with failure
4. Deference to expertise
5. Resilience

6. “Quote”
“The single greatest impediment to error
prevention in the medical industry is that
we punish people for making mistakes.”
(Leape 2009)
Dr. Lucian Leape is a professor at Harvard School of Public
Health, he is a health policy analyst whose research has
focused on patient safety and quality of care

7. http://www.jointcommission.org/assets/1/18/Root
_Causes_by_Event_Type_2004-2Q2013.pdf
Sentinel Event Data - Root Causes by Event Type
April 15, 2014

8. 2014/7/13 8

9. 2014/7/13 9

10. Greatest Challenge at Tawam
• Employees hail from 60 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-
“you made a mistake, and you’re terminated.”

11. When errors occur one of the three
things happen
• It can cause the person to become a champion
Or
• It can cause the person to leave the profession
prematurely
Or
• It can make the person go in to a shell and feel
completely withdrawn and Disengaged.
2014/7/13 11

12. Data source
• Culture of safety assessment surveys
• Incident Reporting system
• System changes initiated through
SEAT
• Celebrating Safety- Staff recognition

13. SAQ’s 2008 & 2010 (ICU CUSP)

15. Safety Event Analysis Teams- SEAT
–A team of believers & opinion builders
–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.
2014/7/13 15

20. System changes –Medication Cabinet
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 drug.
– Reduced the inventory of the Narcotic and Controlled
by 50%. (reduced risk by half)
– ICU physicians and nurses informed about the
changes.
– Periodical review of the usage being carried out.
2014/7/13 20

21. System changes – CVL pull
• Action to secure the Central Line
–Implemented loop dressing to secure the
lines.
–Monitored effectiveness of the system
change.
–Wherever possible considered removing the
CVL.
–Had no incidents thereafter.

22. Staff recognition
In the picture:
Iyad Mahmoud; Jainy Mathew; Lynn Petrie; Krish and Dr. Said Abuhasna
2014/7/13 22

23. System changes -Pressure Ulcers
• 9 PU’s reported between Oct 2011 &Mar 2012
– Joint investigation conducted by wound care nurse
and wound care link nurse.
– Developed Nursing care plans.
– Conducted one to one education.
– Involved Respiratory Therapists.
– Introduced
• Change in policy
• BIPAP vacations
• Gel masks to prevent device related PU’s.

24. Staff recognition -Wound care & RT
In the picture:
Priya Padmanabhan; Stephanie Woodworth; Lynn Petrie; Krish and Dr. Said Abuhasna

25. System changes Misplaced CVL
• Patient had a central line inserted in the ED and arrived
in the ICU.
• The nurse was not sure about the position of the
catheter.
• ICU doctor checked the chest X-ray done in ER
– showed improper position
• Found to be an arterial line.
• Action:
– Post procedure X-ray to be done and the position to be
confirmed prior to shifting patient.
– Post procedure VBG to be checked.

26. Staff recognition
In the picture:
Steve CUSP Executive, Lynn Petrie; Dr. Masood and the RN Sosamma Saji

27. 4
7.6
10.8
0
1.1
1.3
3
3.55
2.2
4.4
1.2
5.3
1.6
5.4
3.8
0
8.6
4.2
1.6
4.5
0
1.5
6.8
3.1
3.6
5.7
1.4
2.9
3.9
2.9
4.1
5
6.1
5.7
2
4.7
1.2
2.7
2.2
00
2
4
6
8
10
12
Blood Culture Contamination Study- ICU CUSP
% Contaminated % CLSI Benchmark Linear (% Contaminated )
Re-education and audits
Causative factors (Baseline assessment)
• Improper hand washing
• Improper site cleaning method prior to collection
• Improper site of collection
• Not adhering to PPE’s
Action
• Group demonstrations
• One to one staff education
• Audits
Causative factors
New hires lack of orientation
American Society for Microbiology & Clinical Laboratory Standards
Institute benchmark for the maximum acceptable contaminated blood
culture is 3%.
Re-education and audits
Created teams for
blood draws
Prevention skill fair
Causative factors
Sustainability

28. Staff recognition
Maryan Dimaano Nurse receiving the certificate of appreciation from Steve Matarelli
CUSP Executive for being part of the blood culture contamination reduction project.

29. Staff recognition
Maria Gomez Nurse receiving the certificate of appreciation from Steve Matarelli
CUSP Executive for being part of the blood culture contamination reduction project.

30. Staff recognition
Lali Varghese Nurse receiving the certificate of appreciation from Steve Matarelli
CUSP Executive for being part of the blood culture contamination reduction project.

31. Staff recognition
Shanthi Subramanian Nurse receiving the certificate of appreciation from Steve
Matarelli CUSP Executive for catching a near miss medication error, that resulted in
a system change in the pharmacy.

32. ICU-CUSP
Jasmin Jamilan Nurse receiving the certificate of appreciation from Steve Matarelli
CUSP Executive for catching a near miss medication error.

34. Implications of SEAT
• The staff came open and reported the incidents
• It helped institute a Fair and Just Culture
• Investigation examined the processes and not just
people.
• Staff share their experiences with other CUSP units.
• SEAT helped turn these staff in to champions.
342014/7/13
Broke the myth
“you made a mistake, you don’t get terminated.”

35. Increasing trend in reporting

36. HSOPS 2012 & 2013 (ICU CUSP)

37. May 2014
ICU CUSP Completed
Six Years

38. References
• Leape LL. Testimony, United States Congress,
House Committee on Veterans' Affairs; 1997 Oct
12.
• Pronovost PJ, Holzmueller CG, Martinez E, et al. A
practical tool to learn from defects in patient
care. Jt Comm J Qual Patient Saf. 2006;32:102-
108.
• Wolf, Z.R & Hughes, R.G. “Error reporting and
disclosure”. In Hughes, R.G (Ed). Patient Safety
and Quality. An Evidence-based handbook for
Nurses. 2008; 35: 333-379.

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