1. “Create A Platform For
Learning From Defects”
A CUSP Approach
Krish Sankaranarayanan MS, MBA, CPHQ
Senior Safety Officer- Tawam Hospital
Presented at the
2nd Annual Drug Safety MENA Summit
13 - 14 February, 2013 - Radisson Blu Yas Island, Abu Dhabi, United Arab Emirates
2013-4-17 1

2. Disclosure
• The presenter has nothing to disclose, nor has
any commercial interest with any of those
information's displayed in this presentation.
2013-4-17 2

3. About Tawam
• Tawam Hospital is a 477-bed tertiary care
facility located in Al Ain, Abu Dhabi, and the
largest of the United Arab Emirates.
• In 2006 Tawam Hospital entered a ten year
affiliation with Johns Hopkins Medicine.
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4. Items for discussion
• Ice breaker- Eric Cropp a pharmacist, the error
that sent him to prison (Video)
• Second Victim
• Culture of Safety
• CUSP Approach- Tawam’s experience
• Learning from defects
• Celebrating Safety
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5. Ice Breaker
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6. Aftermath of an error
Shame & Blame
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7. 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.

8. 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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9. • 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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10. This is what we see?
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11. 2013-4-17 11

12. 2013-4-17 12

13. 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 Child2013-4-17 13

14. Building a Culture of Safety
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15. Safety Culture in High Reliability
Organizations- HRO’s

16. Early adopters- Aviation

17. Definition
• 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.

18. 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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19. On February 22, 2001,
eighteen-month old Josie
King died from medical
errors at the Johns
Hopkins Hospital
19
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)

20. Johns Hopkins Medicine
Comprehensive Unit-based Safety Program
(CUSP)
CUSP is a 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 our mistakes
b) Improve teamwork and communication
Step 6 : Resurvey staff about Safety Culture (annually)
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21. 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
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22. CUSP in Ten Units
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23. Challenges faced
• 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 of, “you made a
mistake, and you’re terminated.”

24. CUSP is a leadership driven &
Partnership driven program
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25. Stakeholders & Team
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26. “Insanity: doing the same thing
over and over again and
expecting different results”
Albert Einstein
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27. “Every system is perfectly designed
to achieve the results it gets.”
Donald Berwick, M.D.
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28. What can we do to improve?
Errors can be prevented by
designing systems that make it
hard for people to do the wrong
thing, and easy for people to do
the right thing.
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29. Critical thinking!!!
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30. System redesign
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31. System Design- Forcing Function
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32. Error Prevention
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• “Smart people learn from their
own mistakes, wise people
learn from other's mistakes.”

33. Formula 1 Pit stop
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34. 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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35. 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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36. Learning from Defects- Tawam
• Creation of 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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37. 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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38. Team members involved being
felicitated
In the picture:
Iyad Mahmoud; Jainy Mathew; Lynn Petrie; Krish and Dr. Said Abuhasna
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39. When errors occur
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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40. Medication Error Story-1
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 402013-4-17

41. Medication Error Story-2
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
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42. Medication Error Story-3
What
Happened
• Remicade a non formulary was administered to the patient (order was
in paper)
• Premedication of antihistamine, panadol 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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43. 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.
432013-4-17

44. 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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45. 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 five seven
principle 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 culture of safety program was existence in the 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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46. PSN -Data
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0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
2011 2012
66.7% 63.1%
26.6% 31.6%
6.7% 5.3%
%ReportedMedicationRelatedEvents
Event Reached the Patient with harm Event Reached the Patient with no harm Near Miss

47. Medication Error Rate
2011 2012
Medication Error Rate
per 10,000 dispensed Items 2.3 1.8

48. Celebrating Safety – Viewing workers
as heroes
• Best Catch Award 2009
• Best Catch Award 2010
• Best Catch Award 2011
• Best Catch Award 2012
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49. • To improve reporting and learn from mistakes.
• To enhance the culture of safety.
• To put focus on processes and at-risk
behaviors, not just on outcomes
• To recognize staff for their contribution to
quality and patient safety.
• To proactively identify and implement risk
reduction strategies
Objectives
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50. Patient Safety Net (PSN)
PSN- Harm Score 1 & 2 (Near Misses)
Data source
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51. • Number of people that could be affected.
• The likelihood of Occurrence
• Severity: The impact(s) of failure
• Detectability
• Followed with a systemic corrective actions or
plan.
Criteria for selection
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52. • Preliminary screening/selection was done by
the department heads.
• Short list Near Misses were submitted to
Senior Leadership Committee for final
selection.
Methodology
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53. Best Catch Award 2009
Synopsis :
• Physician placed an order through HIS for patient for paracetamol 1000 mg PO
PRN Q6H for pain/fever was inadvertently documented as 10,000 mg. The
pharmacy verified this order as such. Nursing caught the error, and called to have
the order modified to paracetamol 1,000 mg PO PRN Q6H for pain/fever.
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Ahlem Hussein RN &
Sharif Deeb Qandil pharmacist
Prevented high dose of
pain medication

54. Best Catch Award 2010
54
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.
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Prevented excess dose of
Chemotherapy medication

55. Best Catch Award 2011
Synopsis :
Rubella vaccine was ordered. The dose was delivered, clearly in a vial which stated 'single dose'. In other
words, the whole vial was a single dose, all of which should be diluted and administered. The pharmacy sent
the dose with a special blue label which called for the nurse to pay attention to the specific dose. The nurse
called to try to understand what was the actual dose. The pharmacist told her she should only give 1/10th of
the vial, once reconstituted. Dr. Jenny who happened to be watching and inspecting the bag with the vaccine
thought this was not right. She called the pharmacy again and this time the pharmacist double checked the
vaccine changed the recommendation to administer the whole vial. If the nurse had given 1/10 of the dose,
the patient would not have been properly immunized.
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Prevented improper
immunization

56. Synopsis :
The pharmacist received a medication refill order from a doctor for a pediatric patient and
noted a mismatch between the refill order and the current medication that the patient was
taking. She contacted the doctor and the child’s mother, verified the medication and corrected
them in the order.
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Best Catch Award 2011
Prevented wrong refill order
of medication

57. Best Catch Award 2011
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.
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Prevented administration of
wrong chemotherapy medication

58. Discussion-The End Game
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59. 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).
http://www.safetyleaders.org/NTSBforHealthcar
e/home.jsp
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60. For hospitals to become safer
• Hospital Leaders must say that they will do
away with errors.
• Hospital Leaders must realize that an event
that occurred in another organization could
one day happen in their hospital.
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61. Positive thing
• UAE-
– 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
• KSA- 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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62. 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/
• http://www.ismp.org/newsletters/acutecare/articles/20091203.asp
• www.emilyjerryfoundation.org
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63. References
• Kohn LT, Corrigan JM, Donaldson MS, editors. To Err Is Human: Building a Safer Health System.
Washington: National Academy Press; 1999
• 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.
2013-4-17 63

64. 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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65. 2 question 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.
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66. Thank You
Patient Safety Top Priority
Patient Safety Everyone's Responsibility
Contacts:
ksankara@tawamhospital.ae
050-9211649
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