1. Cultivating a Non- Punitive Culture Ursula N. Butts VCU MCV Patient Safety Fellowship

2. Purpose of Study 1. Identify the “punitive” and “non-punitive” aspects of CMH culture that may limit error reporting 2. Design a program to cultivate a non-punitive culture and enhance error reporting

3. Opened in 1954. Rural community hospital offering a variety of services and specialties. Original CEO lead hospital for 31 years New CEO 1999, new openness with managers/board Loss of 3 physicians in 2002 Hard to recruit RN’s, use of LPN’s Major recruitment effort Jan. 2003 ~ 20 new nurses

4. Error Reporting System  Paper system  Requires reporter to ID themselves and individual involved in event  Time intensive  Accusatory – employees feel they have been “written up”  Sent to managers for “action” and “recommendations”  Individualizes occurrences, does not trend  Unreported errors identified through other sources

5. And so….  Staff perceive a punitive environment  Which contributes to limited error reporting  Accusatory nature of reporting system inhibits reporting  “Non-punitive” is not understood by management or staff  Not familiar with “systems” approach to errors  Unable to distinguish between competence and accountability

6.  Unreported errors lead to perpetuation of a system or process that is error prone  A punitive, name, blame, shame and train culture does not support error reporting

7.  Increase the error reporting rate  Reduce the perception of a punitive culture  Increase understanding of the system- based causes of error  Separate errors from employee competence measurement and individual accountability

8. Methodology 1. Surveys 2. Education Staff, management, physicians, Board of Trustees, new hires on science of safety e.g. human factors theory, systems theory, methods of high reliability organizations Benefits of non- punitive culture 3. Patient safety commotion 4. Establish multidisciplinary committee 5. Implement improvements 6. Share stories 7. Measure medication error reporting before/after interventions 8. Re-survey staff

9.  September 2002 – Error reporting survey 377 of ~ 700 employees 377 of ~ 700 employees  98% of believe administration communicate patient safety as a high priority- good  15% do not believe individuals are supported for reporting an error  26% nurses/phar. & 41% of other employees report their units place blame  35% nurses/phar feel workload interferes with practicing patient safety.

10. Findings Error Reporting  Fearful of reporting medical errors because: 15% nurses/phar fear losing their job 15% nurses/phar fear losing their job 24% fear being involved in law suit 24% fear being involved in law suit  12% nurses/phar, compared to 27% of other employees, think medication administration procedures are too complex  23% of employees think the error reporting system is difficult  50% of nurse/phar recognize errors result from complex work environment, but 65% of other employees reported

11.  114 licensed personnel responded  71% believe an individuals history of making errors can be used as a valid measure of performance or (67%) competence  32% (35% neutral) felt sanctions for mistakes would produce more careful individuals  52% reported remedial education is the most effective non-punitive remedy  51% did not appreciate hind sight bias  72% believe violation of p&p warrants disciplinary action  22%(32% neutral) believe failure to terminate will be a public relations nightmare

12. Rate of Medication Error Reporting Prior to Interventions Month Total Pt/Days Reported Med Errors Rate per 1000 Pt/days April 2002 6385345.32 May 2002 6344396.15 June 2002 6253233.68 July 2002 6783324.72 August 2002 6665416.15 September 2002 6283304.77 5.13/1000 Pt/Days

13. Rate of Medication Error Reporting Following Interventions Month Total Pt/Days Reported Med Errors Rate per 1000 Pt/days October 2002 6297396.19 November 02 6130315.06 December 02 6402294.53 January 2003 6560203.05 February ‘03 6254203.20 March 2003 6600446.67 4.78/1000 Pt/days

14.  Supports the hypothesis that employees of CMH may hesitate to report errors due to a perception of a punitive culture  ¼ of employees found the error reporting system difficult although the accusatory nature of the form did not present an issue (72% felt comfortable reporting errors made by co- workers)  Nurses/phar reported workload interferes with patient safety BUT 50% do not understand error results from complex systems

15. Cont:  High % of neutral responses (median 26%) indicates confusion  The findings demonstrate a misunderstanding of a non-punitive culture and the perception of a punitive culture at CMH  The rate of medication errors reported actually decreased slightly following education and interventions.  A computer based anonymous reporting system was introduced in April, 2003

16.  Changing an ingrained culture takes time, perseverance, education and patience.  Examples are important!  Meeting with management in order to understand accountability, competence and educational issues is a key to success.

17. Cultivate a non-punitive culture!