MODULE 3

SAFETY CULTURE

LESSON: Patient Safety & Human Factors

 POINT TO PONDER

“A health & safety problem can be described by statistics but

cannot be understood by statistics. It can only be
understood by knowing and feeling the pain, anguish,
and depression and shattered hopes of the victim and
of wives, husbands, parents, children, grandparents and
friends, and the hope, struggle and triumph of recovery and
rehabilitation in a world often unsympathetic, ignorant,
unfriendly and unsupportive, only those with close experience
of life altering personal damage have this understanding.”
VIDEO CLIP THE JOSIE KING CLIP FOR
QSEN
(VIDEOS)
 https://www.youtube.com/watch?v=JeVcXhvPvbU
 Patient safety is the prevention of avoidable errors and
adverse effects to patients associated with health care.

 Staff practise patient safety when they apply safety science

methods towards the goal of developing reliable systems of
care.

 So patient safety is both a characteristic of a healthcare

system and a way of improving the quality of care.
GROWING SAFETY CONSCIOUS ORGANISATIONAL
CULTURES

 Organisational cultures can foster a

proactive approach to patient
safety.
 However we see attitudes and
behaviours that discourage staff from
learning from preventable incidents.
DESIGNING FOR RELIABILITY

 We can increase reliability when there

is: agreement about the way of doing
things; standardisation of elements of
practice; and a commitment to
implement best practice.
 HUMAN FACTORS AS STANDARD IN EDUCATION AND
TRAINING

 The human factors approach to safer

healthcare should be a part of the core
curricula of all health professionals, with
training needs to be co-ordinated along
interprofessional lines.
TERMS
ACTIVE FAILURE

 “These are actions or omissions that are

sometimes called ‘unsafe acts’. They are
actions by frontline healthcare staff who
are in direct contact with patients, and
include slips, lapses, mistakes or
violations of a procedure, guideline or
policy."
 Source: National Patient Safety Agency (2004)
ADVERSE EVENT

 "An adverse event is an injury caused by

medical management rather than the
underlying condition of the patient."
Source: Institute of Medicine (2000)

 "An event or omission arising during

clinical care and causing physical or
psychological injury to a patient."
Source: Department of Health (2000)
 ERGONOMICS
 "Ergonomics (or human factors) is the scientific discipline concerned
with the understanding of the interactions among
humans and other elements of a system, and the
profession that applies theoretical principles, data and methods to
design in order to optimize human well being and overall system."
 "Practitioners of ergonomics, ergonomists, contribute to the
planning, design and evaluation of tasks, jobs, products,
organizations, environments and systems in order to make them
compatible with the needs, abilities and limitations of people."                      
 Source: International Ergonomics Association’s Executive Council (2000) IEA Definitions of
Ergonomics. In W. Karwowski (ed.), International encyclopedia of ergonomics and human factors,
London: Taylor & Francis, pp. 102.
 ERRORS

 "An act of commission (doing something

wrong) or omission (failing to do the
right thing) that leads to an undesirable
outcome or significant potential for such
an outcome."
 Source: Agency for Healthcare Research and Quality,
FORESIGHT

 The ability of frontline healthcare staff

to identify, respond to and recover
from the initial indications that a
patient safety incident could take
place.”
 Source: National Patient Safety Agency (2008)
LATENT CONDITIONS / LATENT ERROR

 "Errors in the design, organization,

training, or maintenance that lead to
operator errors and whose effects
typically lie dormant in the system
for lengthy periods of time".
 Source: Institute of Medicine (2000) 
 MISSED NURSING CARE

 “Missed nursing care is a newly defined concept and

refers to any aspect of required patient care that is
omitted (either in part or in whole) or delayed.
Missed nursing care is an error of omission.
 The patient safety movement has identified two
major types of errors – acts of commission (such as
marking the incorrect eye for surgery) and acts of
omission (such as not ambulating the patient)”.
 Source: Kalish BJ, Landstrom GL, Hinshaw AS (2009) Missed nursing care: a
concept analysis, Journal of Advanced Nursing, 65(7) July, pp.1509-1517.
(Quote from page 1510).
MISTAKE

 "A form of human error where an

individual shows awareness of a
problem, but forms a faulty plan for
solving it. The situation where an
individual does the wrong thing
believing it to be correct".
 Source: Stranks J (2007) Human factors and behavioural safety,
Amsterdam: Elsevier, p.454.
NEAR MISS

 "Situations that could have resulted in

an accident, injury or illness for a
patient but were avoided by chance
or by intervention."
 Source: Milligan F (2007) Malicious and inept practice (in) Currie
L (Ed) Understanding Patient Safety, London: Quay Books, p.55.
NEVER EVENTS

 "Serious, largely preventable patient

safety incidents that should not occur
if the available preventative measures
have been implemented."
 Source: National Patient Safety Agency (2009) 
RESILIENCE

 Resilience moves the focus away from

“What went wrong?” to “Why does it
go right?”, that is, it moves from
simplistic reactions to error making
toward valuing a proactive focus on
error recovery.
RISK MANAGEMENT

 "Identifying, assessing, analysing,

understanding and acting on risk issues
in order to reach an optimal balance
of risk, benefit and cost."
 Source: National Patient Safety Agency (2004) 
SAFETY CULTURE

 “... it is essentially a culture where staff have a

constant and active awareness of the
potential for things to go wrong. It is also a
culture that is open and fair and one that
encourages people to speak up about
mistakes. In organisations with a safety
culture people are able to learn about what is
going wrong and then put things right .”
 Source: National Patient Safety Agency (2004)
SLIPS

 "Failures in carrying out the actions of a

task, that is, actions not as planned."
 Source: Stranks J (2007) Human factors and behavioural safety,
Amsterdam: Elsevier, p.458.
SYSTEM ERROR

 "Although we cannot change the aspects of

human cognition that cause us to err, we can
design systems that reduce error and make
them safer for patients."
"Systems can be designed to help prevent
errors, to make them detectable so they can be
intercepted, and to provide means of mitigation
if they are not intercepted."

 Source: Nolan TW (2000) System changes to improve patient safety,

SENTINEL EVENT

 Any unanticipated event in a

healthcare setting resulting in death
or serious physical or psychological
injury to a patient or patients, not
related to the natural course of the
patient's illness.
Sentinel events include "unexpected occurrences involving death or
serious physical or psychological injury, or the risk thereof" and all of
the following, even if the outcome was not death or major permanent
loss of function:

 Infant abduction, or discharge to the wrong family.

 Unexpected death of a full-term infant.
 Severe neonatal jaundice (bilirubin over 30 milligrams/deciliter).
 Surgery on the wrong individual or wrong body part.
 Instrument or object left in a patient after surgery or another procedure.
 Rape in a continuous care setting.
 Suicide in a continuous care setting, or within 72 hours of discharge.
 Hemolytic transfusion reaction due to blood group incompatibilities. [2]
 Radiation therapy to the wrong body region or 25% above the planned
dose.
VIOLATION

 "A situation where a person

deliberately carries out an action that
is contrary to some rule which is
organizationally required, such as an
approved operating procedure."
 Source: Stranks J (2007) Human factors and behavioural safety,
Amsterdam: Elsevier, p.460.
FACTORS THAT AFFECT SAFETY
1. COMMUNICATION

 A standard model for communication

has a sender converting an idea into a
message using a medium of some
sort (e.g. written record, phone
conversation etc) with which to
transmit a message to one or more
receivers who then translate the
message back to the original idea.
 COMMUNICATION FAILURE:

 Transmission: information not transmitted - message

unclear either due to ambiguity of message, problem with
medium etc.
 Reception: information not received - information sent
but misinterpreted, ignored etc. The timing of message may
cause reception failure.
2. LEADERSHIP

 Effective leadership is characterised by active

engagement for both patients and staff and this
has been shown to have a direct bearing on safer
patient care (West and Dawson 2012).
 Examples of how senior staff can demonstrate the
importance of patient safety include: leadership
"walkrounds" (Thomas et al. 2005; Patient
Safety First 2009) and as role models
(Laschinger and Leiter 2006).
 “Bring me solutions, not problems”
 The best way to influence management is to provide solutions
and not bury them in problems.

 “If you cannot manage safety, you

cannot manage”
 SAFETY CULTURE

 Use of the term safety culture was first recorded in 1988 after the
Chernobyl nuclear power plant disaster (Halligan and Zecevic 2011). 
THE CHERNOBYL DISASTER (BBC)

In the early hours of 26 April 1986,

one of four nuclear reactors at the
Chernobyl power station exploded.
Moscow was slow to admit what
had happened, even after
increased radiation was detected
in other countries.
The lack of information led to
exaggerated claims of the number
killed by the blast in the immediate
area.
Contamination is still a problem,
however, and disputes continue
about how many will eventually
die as a result of the world's worst
nuclear accident.
 The Manchester Patient
Safety Framework (MaPSaF)
is atool to help NHS
organisations and healthcare
teams assess their progress in
developing a safety culture.
The four publicly funded
healthcare systems in the
countries of the United
Kingdom, may be referred
to as the National Health
Service(NHS).
MAPSAF FRAMEWORK
 The five levels describe five distinct safety cultures, from least (pathological) to
most mature (generative) in terms of the perceived attitude to safety issues.
 Pathological: organisations with a prevailing attitude of ‘why waste our time
on safety’ and, as such, there is little or no investment in improving safety.
 Reactive: organisations that only think about safety after an incident has
occurred.
 Bureaucratic: organisations that are very paper-based and safety involves
ticking boxes to prove to auditors and assessors that they are focused on
safety.
 Proactive: organisations that place a high value on improving safety, actively
invest in continuous safety improvements and reward staff who raise safety
related issues.
 Generative: the nirvana of all safety organisations in which safety is an
integral part of everything that they do. In a generative organisation, safety
is truly in the hearts and minds of everyone, from senior managers to
frontline staff.
 (University of Manchester 2006).
STRESS & FATIGUE

 Stress is the "adverse reaction people have to

excessive pressure or other types of demand
placed upon them". (Health and Safety Executive 2007, p.7)
 Fatigue is " the state of tiredness that is
associated with long hours of work, prolonged
periods without sleep, or requirements to
work at times that are “out of synch” with the
body’s biological or circadian rhythm’"(Caldwell and
Caldwell 2003, p.15).
TEAMWORK

 Team dynamics are psychological

processes. They can be seen most
clearly in the way the group interacts.
Team leaders can understand the team
dynamics by looking at how the team
communicates, cooperates,
coordinates and makes decisions.
WORKPLACE HAZARDS

 Workplace hazards are "a set of circumstances or a

situation that could harm a person’s interest, such as
their health or welfare" (Croskerry et al. 2009), p.409).
 Workplace hazards that have been repeatedly
highlighted in studies include
 issues with packaging and labelling of medicines (and
this is something that the National Patient Safety
Agency (NPSA 2007) has looked into),
 on-screen displays (NPSA 2010a) and the
 operability of devices such as infusion pumps (NPSA
2010b).
TWO IMPORTANT TECHNIQUES
THAT ARE USED TO IDENTIFY
RISKS ARE:
ROOT CAUSE ANALYSIS (RCA) -
USED AFTER AN ADVERSE EVENT.

STRUCTURED WHAT IF TECHNIQUE

(SWIFT) - FOR ANTICIPATING ADVERSE
EVENTS.
 ROOT CAUSE ANALYSIS (RCA)
 Designed to explore the contributing factors to adverse clinical events. The
process is based on a sequence of questions.
 What happened?
 How did it happen?
 Why did it happen?
 What can be done to prevent it from happening again?

 The process is described fully on the National Patient Safety Agency

website (NPSA n.d.). A summary of the findings of a research study
exploring the nursing contribution to RCA and the benefits and
challenges involved is described by Mengis and Nicolini (2010).
STRUCTURED WHAT IF
TECHNIQUE SWIFT
 A systems-based risk identification technique
that employs a workshop-based approach with
participants addressing pre-developed
guidewords or headings to examine risks and
hazards at a system level (Card AJ et al 2012b).
 Because of this, the success of the technique is
dependent on a representative group being
available with the right insight into the
systems in question. 
NEW PARADIGM FOR
HEALTHCARE SAFETY
https://www.youtube.com/watch?v=rOrlEmHCUac
2016 Focus: Building a Culture of Safety (ANA)
IMPORTANT IN PROFESSIONAL
NURSING PRACTICE

 Requires all organizations to create a NON-PUNITIVE

culture for error reporting
 “PROCESS or SYSTEM NOT PEOPLE”
Philosophy
 Amy Edmonston ( Havard professor) Best performing nursing units
were those had higher detected rates for adverse drug events.
 Staff’s willingness to report errors contributed to improvement of
processes.

 FAIR & JUST culture (Marx, 2007)

HUMAN FACTORS

 “To err is human.”

 Selective attention
 https://www.imdb.com/video/vi2603596313?playlistId=tt672807
2&ref_=tt_pr_ov_vi

 Optional resource:
 To Err is Human – Documentary Full Movie version and Panel
Discussion, 2018
 Yale University
 https://www.youtube.com/watch?v=88Uae_TXNdQ
ZERO TOLERANCE FOR RECKLESS BEHAVIOR

 Recognizes that competent professionals make

mistakes. They tend to develop unhealthy norms
(shortcuts or routine rule violations).
 Learn from mistakes in order to reduce errors in
the future.
 An individual is accountable to the system, the
greatest error is not to report a mistake and
thereby prevent others from learning
 Everyone should serve as safety advocate.
VIDEO CLIP
NURSING SIMULATION SCENARIO
MEDICAL ERROR
https://www.youtube.com/watch?v=KkSDW44hxTk
2011

 What were the areas of concern or identified gaps in this

situation?
 As a Nurse Manager, how would you address this prevalent
practice?
 What improvement/changes will you adopt to prevent medical
errors
 AS A NURSE LEADER:

 Learn concept & tools

related to risk
identification, analysis &
error reduction
 Adopt a non-punitive
error reporting
 Be constantly vigilant
 Promote communication
 Become a role model for
staff & peers
LEADERSHIP & MANAGEMENT
CLASS DISCUSSION (GRADED
BREAKOUT ACTIVITY)

CASE STUDY:
AN EXTENDED STAY
 MANCHESTER PATIENT SAFETY FRAMEWORK
(MAPSAF)

2006
MODULE REQUIREMENT

 The Manchester Patient Safety Framework (MaPSaF) from the

NPSA is a tool to help NHS organisations and healthcare teams
assess their progress in developing a safety culture.
 The MaPSaF can be used to:
 facilitate reflection on patient safety culture
 stimulate discussion about the strengths and weaknesses of the
patient safety culture
 reveal any differences in perception between staff groups
 help understand how a more mature safety culture might look
 help evaluate any specific intervention needed to change the
patient safety culture.
 Pathological: organisations with a prevailing attitude of ‘why waste
our time on safety’ and, as such, there is little or no investment in
improving safety.
 Reactive: organisations that only think about safety after an incident
has occurred.
 Bureaucratic: organisations that are very paper-based and safety
involves ticking boxes to prove to auditors and assessors that they
are focused on safety.
 Proactive: organisations that place a high value on improving safety,
actively invest in continuous safety improvements and reward staff
who raise safety related issues.
 Generative: the nirvana of all safety organisations in which safety is
an integral part of everything that they do. In a generative
organisation, safety is truly in the hearts and minds of everyone,
from senior managers to frontline staff.

University of Manchester 2006).

 SEATWORK: SHORT
RESPONSE
1. From you limited immersion in the hospitals what could
you say is the level of safety culture based on the MapSaF
tool. And why? (5 points)
2. How do you think you can as a beginning nurse impact the
safety culture in an organization? (10 points)
 THANK YOU.
For safety is not a gadget
but a state of mind.  ~Eleanor Everet