Brian Kaminski, DO, is vice president of Quality and Patient Safety and Patient Safety Officer at ProMedica (Toledo, Ohio) and Medical Director of the Emergency Department at ProMedica Toledo Hospital.
Dr. Kaminski became vice president of quality and patient safety and patient safety officer at ProMedica in 2013. During his tenure, he has implemented safety coaches at all ProMedica acute care locations and helped implement the Agency for Healthcare Research and Quality's CANDOR process, a road map for timely response to unexpected patient harm events. He also established Toledo Talks sessions, through which employees can share results of serious safety event investigations and work to implement lesson learned from root cause analyses. In 2015, Dr. Kaminski became a certified professional in patient safety through the National Patient Safety Foundation.
Their nominator said: “ProMedica Health System has deliberately declared its intent in becoming a zero events of harm organization. Starting in 2013 steps have been taken to improve the culture of safety across the ProMedica system. Special teams have been formed to quantify and improve the number of serious safety events. In the last three years the number of serious events has decreased by approximately 65% and the AHRQ survey has shown positive improvements in all 12 domains.
ProMedica Culture of Safety Milestones
ProMedica is committed to keeping patients, families and employees safe from harm.
At ProMedica, we are committed to keeping our patients, families and employees safe from harm. To do this, everyone uses special tools that improve our ability to maintain a safe environment. Our Error Prevention toolkit serves as a reminder of specific techniques that can help reduce harm and ensure a high level of safety, quality and service to our patients.
At ProMedica, we have made safety, quality and service excellence a strategic priority for the entire ProMedica Care Experience. We believe that creating excellent experiences directly connects with our mission of improving your health and well-being.
Culture of Safety Fundamentals
One of the most important cultural components of safety relates to the organization’s non-punitive response to error. It is our belief that the health care workforce is composed of well intentioned, well-prepared people in a variety of roles and clinical disciplines who do their best every day to ensure that patients are well cared for. It is from this mission of caring for people in times of their greatest vulnerability and need that health care workers find meaning in their work, as well as their experience of joy. It is our goal to shape safety culture through management practices that demonstrate a priority to safety and compassionately engage the workforce to speak about and report errors, mistakes, and hazards that threaten safety - their own or their patients. We do not feel that organizational learning and improved reliability in care delivery can be achieved by punishing people for normal human errors.
One measurement tool that can provide an assessment of this cultural attribute can be obtained by simply surveying the staff. On an annual basis, we survey our workforce on their perception of ProMedica’s deployment of a non-punitive response to error. We ask our staff if they feel “their mistakes and event reports are held against them and that mistakes are not kept in their personnel file.”
As a result of improving the way we respond to errors we have seen a dramatic increase in the number of events reported across our system, thereby allowing us to investigate these events and fix system failures that could lead to a similar event in the future. (See figure 1).
A more detailed view of our Serious Safety Event Rate shows a 55% improvement in our rate of harm from our peak in 2015 to our current state in October of 2018. (See figure 2).
While there are many factors that contribute to an organization’s overall culture of safety, we feel that using the proxy of “Nonpunitive response to error” is a fairly easy and accurate measurement tool to determine how likely errors are to occur through the experiences of the workforce.
Numerous tools and techniques can be applied to create safer environments by reducing power distance and authority gradients that typically exist in a hierarchy. One such tool that we use at ProMedica involves empowering all staff members to speak up for safety. In fact, we feel that it is so important we have created a phrase that we expect everyone in the organization to understand and adopt a nonpunitive response when it is spoken. Our phrase is: “I have a concern.”
When this phrase is used, our hierarchies are suspended, the work stops and the team responds by addressing the concern before moving forward. Although this may seem trivial, it allows for lesser voices in the organization to be heard and removes much of the fear and intimidation that can be associated with speaking up for subordinates within the organization. Importantly, there is no punishment for being wrong in these cases. The work simply proceeds after the concern is resolved, whether or not the individual was correct or incorrect in their assessment.
Following you will see two stories that highlight some of our efforts in action. The act of capturing and sharing these stories across our system plays a vital role in continuing to promote our safety culture.
L&D Nurse Prevents Medication Error
Recently, while on duty in the ProMedica Toledo Hospital (TH) Labor & Delivery unit, Val Olson, RN employed Error Prevention techniques to keep her patient from harm. She was retrieving an intravenous preparation of Pitocin for her laboring patient. Pitocin is a medication commonly used in L&D to help some patients progress in their labor. At TH, Pitocin should come in a 500 ml bag of lactated ringers (LR) with 30 units of Pitocin added. These preparations are prepared in pharmacy and then stocked in the Pyxis machine in L&D, so that they are readily available to the staff there. When Val got a bag of Pitocin from the Pyxis, however, something didn't look right.
The scanning label, which pharmacy applies, clearly stated “Pitocin 30 units in 500 ml LR.” However, as Val looked more closely, she realized what had set off her internal alarm. This preparation was mixed in a solution of D5LR instead of an LR solution. D5LR is a dextrose enriched IV solution which is different from standard LR. If Val had not noticed this subtle difference on the original packaging and taken this bag of Pitocin to the patient's room and scanned it, there would have been no warning because the scanning label would have matched the physician order. The simple human error which occurred in pharmacy would have made it through the barriers we put in place and reached our patient. As soon as Val discovered the error, she alerted pharmacy. Doug Dremann, RPh, TH Pharmacy Director, and his staff worked quickly to inspect their stock and found that there were no other mislabeled IV preparations in the pharmacy stock nor in L&D.
So, why is this story important?
- When Val sensed something was not right, she listened to that "internal alarm" and took a closer look. This enabled her to actually catch the error before it reached the patient. It is a perfect example of our Error Prevention Technique of STOP, REFLECT, RESOLVE.
- Once Val discovered the error, she understood the need to escalate her concern as soon as possible. In this case, there may have been other mislabeled bags in circulation. Thanks to the strong teamwork between the two departments and pharmacy's rapid response, they were able to quickly determine that there were no other issues. This was a great example of our Error Prevention technique ARCC (Ask a question, make a Request, voice a Concern, use Chain of command). In addition, the great teamwork and pharmacy's rapid response to the situation really demonstrates a commitment to resilience, a characteristic of High Reliability.
Thank you Val and Doug for maintaining a personal commitment to the safety of our patients!
IR Nurse Speaks Up for Safety
Deb Hilton, an Interventional Radiology nurse at ProMedica Toledo Hospital, was reviewing cases to prepare for the coming week. While doing so, she noticed that one patient, scheduled for a liver biopsy, already had a Magnetic Resonance Cholangiopancreatography study (MRCP) performed. An MRCP is a non-invasive study which yields very detailed imaging of the liver, pancreas, gall-bladder, bile ducts, and pancreatic duct. Deb's experience told her that, depending on the results, the MRCP may have alleviated the need for a liver biopsy. Once she viewed the results, she felt strongly that the patient might not need the more invasive liver biopsy that had been scheduled. Deb escalated her concern to both the IR physician, Dr. Zakaria Assi and the ordering physician. After reviewing her findings with them, it was determined that the liver biopsy was not needed.
So, why is this story important?
- When Deb noticed the patient had recently had an MRCP, her "internal alarm" sounded, and she heeded it. She took a moment to consider what she should do and resolved to contact the physicians involved and review her findings with them. This perfectly exemplifies use of the Error Prevention Technique Stop, Reflect, Resolve.
- As often happens when we use Stop, Reflect, Resolve, Deb understood the need to employ further Error Prevention tools. In this case, she used ARCC (Ask a question, make a Request, voice a Concern, use Chain of command) to resolve the situation.
- After the situation was resolved, Deb understood the need to Report Problems, Errors, Events, so that we might learn from this event.
This story highlights the challenges in coordinating care for our patients in a healthcare landscape that has grown increasingly more complex. With medicine becoming ever more specialized and multiple physicians involved in the care of our patients, we must recognize we are prone to these types of errors. It is certainly possible that this error would have been discovered at another point, but Deb realized she might have the opportunity to keep it from reaching the patient right now, and this spurred her to action. At the very least, Deb saved our patient from days of worrying about the procedure and the inconvenience of having to show up for it, not to mention the very real possibility of actually enduring the unnecessary procedure.
Thank you Deb for speaking up and for your commitment to safety! Thanks also to the physicians involved for hearing Deb's concern and ensuring that the most appropriate plan of care was realized.
Originally published in Issue 1, 2019 of MTM Magazine.