1. Science of Safety Training
Presented by Krish Sankaranarayanan MS, MBA, CPHQ
Senior Safety Officer
2013-4-17 1

2. Introduction-About me
• Been in healthcare domain for over 24 years.
• Triple Masters degree.
• MS in Patient Safety Leadership from UOI- Chicago.
• Certified Professional in Healthcare Quality (CPHQ)
• Educational consultant- Canadian Healthcare Association-
CQI program
• Membership
– Member American College of Healthcare Executives
– Member National Association of Healthcare Quality
– Member American Society for Healthcare Risk Management
– Member American Society of Professionals in Patient Safety
– Vice President of the ACHE Middle East and North Africa Group

3. Discussion Items
• Ice Breaker- Eric Cropp story (Video)
• Historical context of Patient Safety?
• Second Victim
• Comprehensive Unit-based Patient Safety
program- Josie King Story (Video)
• Learning from defects
• Celebrating Safety
• 2-Question Survey
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5. Aftermath of an error
Shame & Blame
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6. 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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7. The Annual Toll of Medical Injury
IOM “To Err is Human” (1999)
• 44,000 – 98,000 deaths/year in US due
to medical errors.
• $ 50 billion in total costs.
• 7% of patients suffer a medication error.
• Every patient admitted to ICU suffers an
adverse event.

8. Where we stand?

10. 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

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15. Building a Culture of Safety
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16. What is Culture*?:
“The way we do things
around here”
1 attitude = opinion…everyone’s attitude = culture
*aka Climate

17. “Culture is local” and “so is change.”

18. 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.

19. Safety Culture in High Reliability
Organizations- HRO’s

20. Early adopters- Aviation

21. Josie King Story
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23. 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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24. Johns Hopkins 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)

25. 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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26. 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.”

27. Measuring Culture of Safety
tested and well known tools
• Safety Attitudes Questionnaire
• Patient Safety Culture in Healthcare
Organizations
• Hospital Survey on Patient Safety Culture
• Safety Climate Survey
• Manchester Patient Safety Assessment
Framework

28. 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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29. 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.

30. Safety Attitude Questionnaire-(SAQ)
Survey
Targeted Surveys Survey response
Location Year staff Administered Returned rate
Phase 1 CUSP Pilot Units 2008 199 199 199 100%
Phase 2 In-patient areas 2010 1600 1476 1450 98%
Out-Patient & satellite Qtr 4
Phase 3 locations 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.

31. 2008 SAQ Phase-1
(CUSP Pilot Units)
SAQ Results 2008
100%
80%
Average % Positive
60%
ICU
40%
Pediatric Oncology
NNU
20%
0%
Teamwork Safety Job Stress Perceptions Perceptions Working
Satisfaction Recognition of Hospital of Unit Conditions
Management Management
Domain

32. 2010 SAQ Phase-2
(All In-patient Units- & CUSP Pilot Units Re-survey)

33. 2011 SAQ Phase-3
(Out-patient Units)

34. Leadership Assigned to
Twelve CUSP units
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35. CUSP is a leadership driven &
Partnership driven program

36. Stakeholders & Team

37. 2 question survey: CUSP Expansion 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.
2-item Staff Safety Survey
30%
25%
20%
15%
ICU N=93
NICU N=73
10% Peds Onc N=39
5%
0%
Communication Staffing Medication Infection Policies & Education Equipment Others
& Teamwork Errors Control Procedures
Areas of concern

38. 2 question survey: CUSP Expanded
Units- 2010 & 11
• 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.
2-Question survey
Other
Equipment/Environment/facilities
Education Obgyn
Policies/Procedures and systems
Surg 2
Surg 1
Infection Control
Daycase
Medication Errors Med 2
Med 1
Staffing
Communication/Teamwork
0% 10% 20% 30% 40% 50% 60%

39. Peds Oncology - CUSP Meeting Peds Oncology - CUSP Meeting
ICU- CUSP Meeting
NNU- CUSP Meeting
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40. ICU- CUSP Executive Walk rounds
Peds Oncology - CUSP Executive Walk rounds
Steve Talking to the House Keeping staff

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

42. ICU CLABSI Free Days
CUSP Team with the ICU Executive - COO
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43. NNU CLABSI Free Days
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44. “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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45. 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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46. “Insanity: doing the same thing
over and over again and
expecting different results”
Albert Einstein
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47. “Every system is perfectly designed
to achieve the results it gets.”
Donald Berwick, M.D.
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48. Not Bad people - But Bad Systems
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49. 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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50. Critical thinking!!!
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51. System redesign
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52. System Design- Forcing Function
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53. Error Prevention
• “Smart people learn from their
own mistakes, wise people
learn from other's mistakes.”
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54. Formula 1 Pit stop
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55. 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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56. 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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57. 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.
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58. Medication Error Story-1
First Nurse proceeded
to administer the
vaccine without taking
Second Nurse baffled after seeing the tablet PC to the
the expiration date and the patient bed side
missing expiration date in the Expired vaccine
label arrived from
Pharmacy
Error reached Double check for
the patient but expiration date not
did not cause done properly
harm
Vaccine Injected and
asked second Nurse to
chart in Cerner on his
behalf
SWISS CHEESE MODEL
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59. Medication Error Story-2
Chemotherapy
Written by MD. Checked
Vincristine according Prepared by
doxorubicin To the protocol Pharmacy
And Then faxed Medication
l_aspargenes to pharmacy Received from
Pharmacy,
Checked with
Another
Two medication Chemotherapy
taken to Competent
patient room Nurse
VCR VCR
and DOXO
L-Asp returned to
DOXO L-Asp
fridge
And
Emla cream
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60. Medication Error Story-3
• Remicade a non formulary was administered to the patient (order was
in paper)
• Premedication of antihistamine, panadol was ordered in CERNER
What which was not communicated to the nurse
Happened
• The patient developed allergic reactions
• Investigation revealed that there was no set protocols or guidelines
• Break down in communication & information transfer
What Next
• Guidelines, protocols and checklist were developed
• No incidents since then
Action
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61. 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 shared their experiences with other
CUSP units.
• The three nurses have now become our patient
safety champions.
Broke the myth-“you made a mistake, and don’t get terminated.”
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62. 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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63. Impact of CUSP on the
staff
CUSP Can turn ordinary people in to
champions
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64. Best Catch Award program
Celebrating Safety – Viewing workers as
heroes
• Instituted in 2009 for the best near miss caught.
• Now in the fourth 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.

65. Best Catch Award 2010
Pediatric Oncology- CUSP
Prevented excess dose of
Chemotherapy medication
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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66. Best Catch Award 2011
ICU- CUSP
Rhian Evans
Associate Nurse Manager – ICU
receives the award from the CEO
Mr. Gregory Schaffer
Prevented cauterization
and accidental fire in the
ICU
Synopsis :
Cauterization (ritualistic burning) Prevented family from approaching patient on
ventilator with hot burning coal in patient room. Coal was extinguished safely.
Resulted in system and policy changes.

67. Best Catch Award 2011
NNUCUSP
Asuncion Carlos
Sr. Respiratory Therapist -
receives the award from the
CEO Mr. Gregory Schaffer
Prevented inappropriate
order for therapy
Synopsis :
An inappropriate order for heliox therapy for NNU patient was not carried out.
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68. Best Catch Award 2012
Peds Oncology CUSP
Prevented administration of wrong
chemotherapy medication
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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69. Arab Health Awards
• Tawam’s patient safety initiatives were
shortlisted for Arab Health in 2010 and 2011
awards and bestowed “commendable.”

70. Dr. Prathap C Reddy’s Safe Care
Awards 2011 India –Judging Panel
Dr Pranav Mehta
VP Physician & Ambulatory Care Services, North Shore Long Island Jewish
Healthcare System & Examiner of prestigious National Malcolm Baldrige Quality
Award
Ms. Diane C. Pinakiewicz
President-National Patient Safety Foundation
Ms. Manisha Shah VP -National Patient Safety Foundation
Ms Ann Jacobson
Executive Director International Accreditation, JCIA
Dr Cyrus Engineer
Manager, WHO Patient Safety project, Johns Hopkins

71. Award being received from the
Chief Minister of the Indian State of
Andhra Pradesh
Awarded to Tawam Hospital for the project title- Establishing “Culture of Safety”-A UAE Hospital
Experience
His Excellency Nallari Kiran Kumar Reddy, Hon'ble Chief Minister of Andhra Pradesh standing
fourth from left, gives away the award. Also present Diane C. Pinakiewicz President NPSF and Dr
Prathap C Reddy, M.D, MBBS, FCCP, FICA, FRCS Apollo Hospital Group India

72. Presented in conferences
1. Speaker at the Patient Safety Congress–IIRME Abu Dhabi- October 2009.
2. Speaker at the ICHA Convention for Patient Safety -New Delhi India- October 2009
3. Speaker at the Healthcare Management Forum -IIRME Dubai- January 2010.
4. Submitted poster at the International Forum on Quality and Safety in Healthcare at Nice-April 2010.
5. Submitted poster at the Patient Safety Congress in UK-May 2010.
6. Speaker at the Quality Standards and Accreditation Conference at Dubai -June 2010.
7. Presented poster at the 13th International Conference on Emergency Medicine at Singapore-June 2010.
8. Speaker at the Safety 2010 World Conference at UK- September 2010.
9. Speaker at the Patient Safety Congress–IIRME Abu Dhabi-October 2010.
10. Speaker at the International Patient Safety Conference-AIIMS New Delhi-October 2010.
11. Speaker at the Healthcare Management Forum -IIRME Dubai- January 2011.
12. Speaker at the First International Conference on Patient Safety -Oman-February 2011.
13. Speaker at the KFSHD -Quality and Safety Event –Saudi Arabia-April -2011.
14. Speaker at the Patient Safety Congress- Best Practices for Asia- India-April 2011.
15. Speaker & Organizer of 2nd Tawam’s Patient Safety Conference- Al Ain- June 2011.
16. Speaker at the at the XIX World Congress on Safety and Health at Work- Turkey- Sep 2011.
17. Speaker at the 3rd Johns Hopkins Medicine Annual Patient Safety Summit- Baltimore USA- June 2012
18. Speaker by Tel-Conference at the URMPM WORLD CONGRESS -UK, Sep 2012.
19. Presented poster at the 5th Medication Safety Conference-Abu Dhabi-Nov 2012.
20. Speaker at the 2nd Drug Safety MENA Summit-Abu Dhabi-February 2013.
21. Member Scientific Advisory Board and Speaker at the Patient Safety & Quality Congress Middle East- Abu Dhabi- March 2013
22. Speaker at The 15th Annual NPSF Patient Safety Congress- USA- May 2013
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73. 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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74. Thank You

75. 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?
2013-4-17 75