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December 2013 Archive for High Reliability Healthcare

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Observations and Lessons Learned on the Journey to High Reliability Health Care.

Blameless or blameworthy errors – does your organization make a distinction?

Dec 18, 2013 | Comments (2) | 14965 Views

Ronald Wyatt, Medical Director, The Joint CommissionBy Ronald M. Wyatt, M.D., M.H.A.
Medical Director
The Joint Commission

Critical to establishing a safety culture is a non-punitive reporting culture. The aim of a safety culture is not a “blame free” culture, but one that balances learning with accountability, assesses errors and patterns in a uniform manner, and eliminates unprofessional (intimidating) behaviors. A safety culture fully supports high reliability and is focused on three attributes: trust, report and improve. Leaders must provide and encourage the use of systems for blame free internal reporting of a system or process failure.

The Joint Commission provides healthcare organization leaders with a framework to strengthen an organization’s culture, which reflects the beliefs, attitudes, and priorities of its staff and employees. Successful healthcare organizations will work to develop a culture of safety and quality. This foundation is found under the Leadership chapter in our accreditation manuals. The five key systems – using data, planning, communicating, changing performance, and staffing – serve as pillars which the leaders use to support the individual care, treatment, and services they provide.

There has to exist, within the organization, an equitable and transparent process for recognizing and separating small, blameless errors that fallible humans make daily, from the unsafe or reckless acts that are blameworthy.2 The trust, report, and improve cycle allows proactive and reactive risk reduction because staff report errors, close calls, and unsafe situations. Proactive risk reduction solves problems before patients are harmed (similar to failure mode and effect analyses) and reactive risk reduction attempts to prevent problems from harming patients again (root cause analyses).

Safety culture is about good safety management established by organizations with a holistic, whole-of-community, whole-of-life approach. Good safety culture implies a constant assessment of the safety significance of events and issues so that the appropriate level of attention can be given. A strong safety culture is dependent first and foremost on the organization’s ability to properly manage safety in the facility over time.

Dr. James Reason advocates that three ingredients are absolutely vital for driving safety culture: commitment, competence, and cognizance – the three Cs. When a patient safety event is initiated by an honest error, the entire system that supports the performance in question should be evaluated. Events triggered by human error are often symptomatic of a system failure. Instead of asking how the individual failed the organization at the sharp end, the more appropriate question is “how did the organization fail the individual?” What flaws or oversights in work processes, policies, or procedures contributed, promoted, or allowed the error and event to occur, at the blunt end? Because the majority of the causes of events originate in the system of controls, processes, and values that are established by the management team, management's first reaction to events should be to look within the organization.1

Second, if an incident is observed or reported in an organization, and it has the potential to cause or has caused patient harm, it is important that organization leaders use a process improvement methodology in all departments, programs, and services to monitor problem-prone or high-risk areas, identify root causes of these adverse events, and disseminate lessons learned to staff members. The Joint Commission recommends Robust Process Improvement (RPI), which is centered on leadership, culture of safety, Lean Six Sigma and change management.In a safety culture there exists:

  • High levels of trust

  • Codes of behavior that are self-governed

  • Personal accountability – recognized by all staff

  • Equitable and transparent disciplinary procedures

  • Close calls and unsafe conditions are routinely reported

  • Proactive assessment of system weaknesses, and weaknesses are addressed

In order for the safety culture to progress, the elements of a culture must be measured. The culture survey should be evaluated, analyzed and result in specific, focused interventions based on areas where the organization is coming up short.

As Gene I. Rochlin, an expert on the social construction of safety, wrote, “the search for safety is not just a hunt for error.”3


  1. Department of Energy Human Performance Textbook, chapter 4
  2. Chassin, M, Loeb, J: The Milbank Quarterly, 2013; 91(3)459-490
  3. Rochlin, GI: Ergonomics, 1999, 42(11)1549-1560


Our children’s health depends on appropriate imaging practices & shared decisions

Dec 04, 2013 | Comments (0) | 7163 Views

By Daniel J. Castillo, M.D., M.B.A.
Medical Director
The Joint Commission

“Don’t talk to me about X-rays, I am afraid of them.” – Thomas Edison, 1903

II want to tell you about the death of a man named Clarence Madison Dally. Though it was over a century ago, the story of his demise has many lessons for us today. Mr. Dally was Thomas Edison’s assistant during Edison’s work developing the fluoroscope. A handsome man with a scientific mind, Mr. Dally functioned as a guinea pig for Edison’s early work with diagnostic radiation, which unfortunately for him, was not considered dangerous at the time. Due to this exposure, Mr. Dally eventually developed radiation burns to his skin and non-healing ulcers to his hands requiring multiple skin grafts. Eventually, this attractive man’s spreading wounds necessitated amputation at his left shoulder and right elbow. Despite these interventions, Clarence Madison Dally died in 1904, from complications of a mediastinal cancer. Mr. Edison, witnessing his assistant’s grotesque transformation, and after uttering the quote above, never worked with X-rays again.

But that was before we knew of the dangers of diagnostic radiation, and detrimental exposure like that would never happen today … right? The following report to the California Department of Public Health occurred just five years ago.

After falling off his bed, a 2-year-old boy was taken to a local hospital where he received 151 scans of his head and neck. The CT scan was stopped only after the boy’s father, who had been holding him, said it was taking too long. The boy’s left and right cheeks showed redness and there was a clear line on his face consistent with the area that had received excessive radiation. A physicist later estimated that the child had a lifetime increased risk of a fatal cancer of 39 percent (AuntMinnie.com, March 24, 2009; New York Times, October 16, 2009).

There is no doubt that ionizing radiation can improve diagnostic accuracy, preventing some patients from undergoing unnecessary surgery, and it can even save lives. Yet, this benefit is not without a cost.  Though there is debate about the magnitude of the relationship, there is no dispute that ionizing radiation is a carcinogen, and that children are especially susceptible to its damaging effects. A recent article in JAMA Pediatrics found “the use of CT doubled for children younger than 5 years of age and tripled for children 5-14 years of age between 1996 and 2005, remained stable between 2006 and 2007, and then began to decline” (Miglioretti, et al., 2013). The authors further state the 4 million pediatric CT scans of the head, abdomen/pelvis, or spine performed each year are projected to cause 4,870 future cancers. We have failed to heed Mr. Edison’s warning.

The significant increase in diagnostic radiation exposure is from both the variation in the dose with each exam as well as the exponential increase in providers’ ordering practices. To help ensure, or at least make more likely, that the imaging study will not have significant variance in radiation dose by using child-sizing protocols, The Joint Commission has called for the use of the ALARA (as low as reasonably achievable) guidelines as well as the recommendations from the Society for Pediatric Radiology’s Image Gently guidelines, and, for adults, Image Wisely (developed by the American College of Radiology and the Radiological Society of North America in collaboration with the American Association of Physicists in Medicine and the American Society of Radiologic Technologists). Equally important are proper training of radiation technologists who perform the examinations, and that the radiologists involved verify that the proper dose protocol is in place for the patient being imaged. These steps will hopefully curb the significant dose variation, which can be as much as a 13-fold difference between the highest and lowest dose in one study (Smith-Bindman, et al., JAMA Internal Medicine, 2009). But, standardizing the dose is only one aspect of controlling diagnostic radiation exposure. 

Providers also need to curb the amount of inefficient radiologic ordering decisions, or I-RODs. I define an I-ROD to be when the decision to order a study, like a CT scan, is made that is incongruous with what a shared decision would be if the patient (and the patient’s family) and provider had access to perfect information and the shared decision is made in an environment devoid of emotion. I freely admit, this is easier said than done. A study from JAMA found that even though the ordering of CT scans and MRIs has exponentially increased over the last 10 years, the likelihood of a patient having a life-threatening condition was constant (Korley, et al., 2010). This is documented proof of the rise of I-RODs. Following guidelines, and more importantly, communicating these guidelines with patients and their families, can lead to more efficient radiologic ordering decisions (E-RODs). An example of this that I used in practice was to print out and provide for the patient and family the guidelines for minor head trauma and head CTs in children. Then, this prompted a discussion and shared decision that increased the probability of E-RODs dramatically. 

Hopefully, these practices can help decrease the diagnostic radiation exposure for the public, and especially, our kids. I’m sure Clarence Madison Dally and Thomas Edison would approve of these efforts.