The Comprehensive UnitBased Safety Program CUSP Culture Teamwork

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The Comprehensive Unit-Based Safety Program (CUSP) Culture, Teamwork, and Clinical Improvement Armstrong Institute for

The Comprehensive Unit-Based Safety Program (CUSP) Culture, Teamwork, and Clinical Improvement Armstrong Institute for Patient Safety and Quality Presented by: Melinda D. Sawyer, MSN, RN, CNS-BC Assistant Director, Patient Safety © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011

Objectives • Explain the relationship between patient safety culture, CUSP, and clinical outcomes •

Objectives • Explain the relationship between patient safety culture, CUSP, and clinical outcomes • Describe the foundational elements of the CUSP program • Identify the 5 steps of CUSP • Describe how staff empowerment and role modeling will support positive culture 2 Armstrong Institute for Patient Safety and Quality

RAND Study Confirms Continued Quality Gap Condition Percentage of Recommended Care Received Low back

RAND Study Confirms Continued Quality Gap Condition Percentage of Recommended Care Received Low back pain 68. 5 Coronary artery disease 68. 0 Hypertension 64. 7 Depression 57. 7 Orthopedic conditions 57. 2 Colorectal cancer 53. 9 Asthma 53. 5 Benign prostatic hyperplasia 53. 0 Hyperlipidemia 48. 6 Diabetes mellitus 45. 4 Headaches 45. 2 Urinary tract infection 40. 7 Hip fracture 22. 8 Alcohol dependence 10. 5 Mc. Glynn et al, NEJM 2003; 348(26): 2635 -26453

What Are Core Aspects of Safety Culture… Formal and informal leader actions & expectations

What Are Core Aspects of Safety Culture… Formal and informal leader actions & expectations Teamwork processes (e. g. , back-up behavior) Feedback, reward, and corrective action practices Communication patterns & language Resource allocation practices Culture of Safety Error-detection and correction systems 4 Armstrong Institute for Patient Safety and Quality

Culture Change is Hard Because Culture has Three Layers… (Schein, 2010; Scorzoni, 1982) 1.

Culture Change is Hard Because Culture has Three Layers… (Schein, 2010; Scorzoni, 1982) 1. Behaviors, norms, processes enacted on the job, feedback & reward systems 2. Espoused values, goals, philosophies, formal policies 3. Underlying assumptions 5 Armstrong Institute for Patient Safety and Quality

Culture Change is Hard Because Culture has Three Layers… (Schein, 2010; Scorzoni, 1982) 1.

Culture Change is Hard Because Culture has Three Layers… (Schein, 2010; Scorzoni, 1982) 1. Behaviors, norms, processes enacted on the job Safety climate surveys focus diagnostic measurement here 2. Espoused values, goals, philosophies, formal polices 3. Underlying assumptions 6 Armstrong Institute for Patient Safety and Quality

Culture Change is Hard Because it Involves both Unlearning and Re-Learning Refreeze Learn &

Culture Change is Hard Because it Involves both Unlearning and Re-Learning Refreeze Learn & Rebalance Unfreeze §Motivation to change §Disconfirming information §Creating psychological safety to overcome change anxiety Lewin, 1951; 7 Schein, 2009

Culture Change is Hard Because it Involves both Unlearning and Re-Learning Refreeze Learn &

Culture Change is Hard Because it Involves both Unlearning and Re-Learning Refreeze Learn & Rebalance Unfreeze § Learning new concepts & standards § Reframing & reinterpreting old § Imitation and identification with roles models § Trial-and-error learning Lewin, 1951; 8 Schein, 2009

Culture Change is Hard Because it Involves both Unlearning and Re-Learning Refreeze Learn &

Culture Change is Hard Because it Involves both Unlearning and Re-Learning Refreeze Learn & Rebalance Unfreeze § Internalize new concepts, meaning, and standards § Incorporate into normal operations & crisis events Lewin, 1951; 9 Schein, 2009

Best Practices for Promoting a Culture of Safety Most effective driver of safety culture

Best Practices for Promoting a Culture of Safety Most effective driver of safety culture = Salient leadership and peer commitment to safety as #1 priority 1. Align espoused values and actual practices § Prioritize safety in business decisions § Articulate vision in terms of desired behaviors 2. Engage and create ownership among frontline team members § E. g. , Learning from defects, investigating most common workarounds 3. Increase visibility around safety § Safety walkrounds, townhalls 4. Deliberate role modeling & coaching Armstrong Institute for Patient Safety and Quality 10

Best Practices for Promoting a Culture of Safety 5. Clearly define and reinforce expectations

Best Practices for Promoting a Culture of Safety 5. Clearly define and reinforce expectations regarding behaviors and attitudes § Empower all staff to stop the line 6. Build reporting structures that engage continuous learning & improvement § Feedback & transparency (response of leadership and peers matters) 7. Create a common language and dialogue often about safety § Standardize communication that facilitates learning and identification of glitches/concerns (e. g. , briefing, 11 debriefing) Armstrong Institute for Patient Safety and Quality

Interventions to Promote Safety Culture: Systematic Review (Weaver, Dy, Lubomski, Wilson, in press) •

Interventions to Promote Safety Culture: Systematic Review (Weaver, Dy, Lubomski, Wilson, in press) • 2750 articles 133 full review 18 included • 61% = multi-faceted interventions – 33% included team-training – 22% included executive walkrounds – 22% included comprehensive unit based safety program (CUSP) • 50% significantly improved safety culture survey scores • 40% also reported other outcomes • Rates of reported errors resulting in pt. harm (Abstoss et al. , 2011) • Rates of RRS activations that resulted in codes (Donahue, 2011) • Adverse outcomes (Riley, et al. , 2011) 12 Armstrong Institute for Patient Safety and Quality

CUSP: Comprehensive Unit-based Safety Program CUSP = A safety improvement strategy that integrates communication,

CUSP: Comprehensive Unit-based Safety Program CUSP = A safety improvement strategy that integrates communication, teamwork, and leadership to create and support a culture of patient safety that can prevent harm, and improve clinical processes and outcomes.

Using CUSP Tools to Improve Patient Safety Culture (For Clinical Areas With < 60%

Using CUSP Tools to Improve Patient Safety Culture (For Clinical Areas With < 60% Agreement) TEAMWORK CLIMATE § § § § § Morning/Shift Briefings Daily Goals Shadowing Exercise OR Briefings SBAR Simulation Team Training Culture Debriefing. Tool Reach out within this hospital • Consult with other clinical areas that have 80% teamwork climate or higher, as they have a consensus of excellence SAFETY CLIMATE § Executive Partnership Training • Use this for your lowest scoring clinical areas first, as it is a powerful intervention, more targeted than traditional executive walkrounds § Hero Form (Feedback from Frontline Workers) § Root Cause Lite § Science of Safety Training • 45 Minute online course; free registration is required • Culture Debriefing Tool Reach out within this hospital • Consult with other clinical areas that have 80% safety climate or higher, as they have a consensus of excellence 14

How does CUSP Contribute to a Culture of Safety? • Designed to improve safety

How does CUSP Contribute to a Culture of Safety? • Designed to improve safety culture and help staff learn from mistakes • Integrates safety practices into the daily work of a unit or clinical area • Provides a scalable intervention – Can be implemented throughout the hospital or organization • Draws wisdom frontline staff to fix hazards – Creates the forum necessary to speak up • Empowers staff to improve safety culture

What are the foundational elements of CUSP? • • Focus on systems, not individuals

What are the foundational elements of CUSP? • • Focus on systems, not individuals Value communication and teamwork Value infrastructure and support Accept responsibility for the systems in which we work • Recognize that culture is local • Respect transparency

CUSP Pre-CUSP 1. Conduct a Culture Assessment 1. Train Staff in the Science of

CUSP Pre-CUSP 1. Conduct a Culture Assessment 1. Train Staff in the Science of Safety 2. Establish an Interdisciplinary CUSP Team 2. Engage Staff to Identify Defects 3. Identify a Senior Executive 3. Senior Executive Partnership/Safety Rounds (Kick-off Meeting) 4. Gather Unit Information 4. Learn from Defects 5. Implement Tools for Improvement

Who is essential to the CUSP Team? Frontline Staff Patient Safety Coordinator/ Patient Safety

Who is essential to the CUSP Team? Frontline Staff Patient Safety Coordinator/ Patient Safety Officer Senior Hospital Executive CUSP Nurse Manager CUSP Coach CUSP Unit Champion Physician Champion 18 Armstrong Institute for Patient Safety and Quality

CUSP – Step 1 - Train Staff in the Science of Safety Training principles:

CUSP – Step 1 - Train Staff in the Science of Safety Training principles: • Understand that safety is a property of systems • Identify principles of safe design (standardize, create independent checks, learn from mistakes) • Understand that teams make wise decisions with diverse and independent input • Recognize that principles of safe design apply to both technical and team work

CUSP – Step 2 – Identify Defects Defect = anything the you don’t want

CUSP – Step 2 – Identify Defects Defect = anything the you don’t want to happen again! • Staff Safety Assessment- all staff are asked to identify: – How will the next patient will be harmed? – What can we do to prevent that harm? • Use defects identified in the event reporting system • Use results from your culture assessment scores and debreifings Armstrong Institute for Patient Safety and Quality 20

CUSP – Step 3 – Executive Partnership Senior Executive Partnership: • Goal = bridge

CUSP – Step 3 – Executive Partnership Senior Executive Partnership: • Goal = bridge the gap between senior management and frontline staff • The role of the senior executive is one of advocacy and action in support of the unit’s safety efforts • The executive is encouraged to discuss safety issues, help to remove barriers, and implement improvement efforts

CUSP – Step 4 - Learn from Defects Learning from Defects tool: 1. What

CUSP – Step 4 - Learn from Defects Learning from Defects tool: 1. What happened? 2. Why did it happen? 3. What did you do to reduce risk? 4. How do you know risks have been reduced?

What Will You Do to Reduce the Risk? • Safe design principles – Standardize

What Will You Do to Reduce the Risk? • Safe design principles – Standardize what we do − Eliminate defects – Create independent checks – Make it visible • Safe design applies to technical and team work 23 © JHU and JHHS, 2011

Error-Proofing Strategies Eliminate Replace Prevent error from occurring Prevent Facilitate Error-Proofing Minimize harm resulting

Error-Proofing Strategies Eliminate Replace Prevent error from occurring Prevent Facilitate Error-Proofing Minimize harm resulting from error Detect (and correct) Mitigate 24 © JHU and JHHS, 2011

Six “Error-Proofing” Strategies ( in order of effectiveness) Strongest 1. Eliminate - eliminate the

Six “Error-Proofing” Strategies ( in order of effectiveness) Strongest 1. Eliminate - eliminate the task or part 2. Replace - use a more reliable process 3. Prevent - engineer so mistakes harder to make 4. Facilitate - make work easier to perform correctly 5. Detect - make mistakes more visible Weakest 6. Mitigate - minimize the effects of errors © JHU and JHHS, 2011 25

Preventing the Error from Occurring • Eliminate Source: www. mistakeproofing. com Eliminate the step

Preventing the Error from Occurring • Eliminate Source: www. mistakeproofing. com Eliminate the step of turning headlights on and off… Spawned from accidents that occurred because people forgot to turn lights on going through tunnels © JHU and JHHS, 2011 26

Preventing the Error from Occurring • Replace Smart Infusion Pumps 27 © JHU and

Preventing the Error from Occurring • Replace Smart Infusion Pumps 27 © JHU and JHHS, 2011

Preventing the Error from Occurring ) • • Color coding Geometric shapes Pins Labeling

Preventing the Error from Occurring ) • • Color coding Geometric shapes Pins Labeling Many Poka-Yoke ideas are the result of preventing a recurrence of an error/harm that has occurred. 28 © JHU and JHHS, 2011

Preventing the Error from Occurring • Prevent Air and Oxygen valves will only fit

Preventing the Error from Occurring • Prevent Air and Oxygen valves will only fit in their corresponding outlets. All of the gas valves have a pin at 12 o’clock, the other pin differs in location. The second pin for medical air is at 4 o’clock © JHU and JHHS, 2011 29

Preventing the Error from Occurring • Facilitate Source: www. mistakeproofing. com Makes it easier

Preventing the Error from Occurring • Facilitate Source: www. mistakeproofing. com Makes it easier to follow at a safe distance © JHU and JHHS, 2011 30

Preventing the Error from Occurring • Facilitate © JHU and JHHS, 2011 31

Preventing the Error from Occurring • Facilitate © JHU and JHHS, 2011 31

Preventing the Error from Occurring Facilitate TALLman lettering to differentiate LASA meds (look alike,

Preventing the Error from Occurring Facilitate TALLman lettering to differentiate LASA meds (look alike, sound alike) 32 © JHU and JHHS, 2011

Minimize the Harm from Error • Detect Source: www. mistakeproofing. com 33 © JHU

Minimize the Harm from Error • Detect Source: www. mistakeproofing. com 33 © JHU and JHHS, 2011

Minimizing the Harm from Error • Mitigate Source: www. mistakeproofing. com Source: www. 500

Minimizing the Harm from Error • Mitigate Source: www. mistakeproofing. com Source: www. 500 sec. com 34 © JHU and JHHS, 2011

Facilitation vs. Prevention • Facilitation • Prevention Source: www. mistakeproofing. com © JHU and

Facilitation vs. Prevention • Facilitation • Prevention Source: www. mistakeproofing. com © JHU and JHHS, 2011 35

Rank Order of Error Reduction Strategies Eliminate Replace Facilitate Forcing functions and constraints Eliminate

Rank Order of Error Reduction Strategies Eliminate Replace Facilitate Forcing functions and constraints Eliminate Automation and computerization Replace Standardization and protocols Replace Checklists and double check systems Facilitate Rules and policies Facilitate Education / Information Facilitate Be more careful, be vigilant © JHU and JHHS, 2011 Facilitate 36

CUSP Step 4: Learning from Defects. Summarize and Share Findings • Summarize findings (Case

CUSP Step 4: Learning from Defects. Summarize and Share Findings • Summarize findings (Case Summary) • Share within your organization • Share de-identified findings with other organizations 37 © JHU and JHHS, 2011

CUSP – Step 5 - Implement Teamwork Tools to improve: 1. Daily Goals Checklist

CUSP – Step 5 - Implement Teamwork Tools to improve: 1. Daily Goals Checklist 2. Morning Briefing 3. Observing Rounds 4. Shadowing another Profession 5. Culture debriefing Tool 6. Physician Call List

CUSP IMPROVING CULTURE, CLINICAL PROCESSES, AND OUTCOMES 39 Armstrong Institute for Patient Safety and

CUSP IMPROVING CULTURE, CLINICAL PROCESSES, AND OUTCOMES 39 Armstrong Institute for Patient Safety and Quality

Identified concern from Staff Safety Assessment (CUSP Step 2) Recommended Improvements (CUSP Step 4

Identified concern from Staff Safety Assessment (CUSP Step 2) Recommended Improvements (CUSP Step 4 & 5) Interventions Implemented Risk of central line associated bloodstream infections Make sure best practices are used for all central lines insertions. A line cart and checklist is used for all central lines insertions. Risk of central line associated bloodstream infections due to poor compliance with IV tubing changes Make sure every central line IV tubing is changed according to best practice. New IV tubing labeling system used. Risk of medication errors Point of care pharmacist available on units Pharmacist assigned Poor management of pain Create guideline or protocol for pain assessment and management Pain card at every bedside Poor communication among ICU providers Create Short Term Goals Sheet Short term goals sheet used during rounds Poor communication during ICU discharge leading to medication errors in transfer orders Implement medication reconciliation process at ICU discharge Medication reconciliation done at discharge

30 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan

30 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar April May June July August Rate/1, 000 Catheter days ICU Catheter-Associated Bloodstream Infections Education Line Cart Checklist 20 10 NHSN Mean 0

Risk of Medication Errors • Pharmacist participation on daily rounds in the ICU associated

Risk of Medication Errors • Pharmacist participation on daily rounds in the ICU associated with: – 66% reduction in adverse drug events (ADEs) – ADEs reduced 10. 4/ 1000 pt days to 3. 5 – Prevent one ADE every 143 patients Leape • Required significant resources – Executive partner was able to obtain the required resources for 1 st ICU – Pharmacists are now assigned to every inpatient unit at JHH. • Survey conducted in 2009 to Dept. of Medicine nurses showed unit-based pharmacists were rated #1 improvement in medication safety

STAT Medication Process Delays • Same survey conducted in 2009 revealed #1 concern with

STAT Medication Process Delays • Same survey conducted in 2009 revealed #1 concern with medication safety was delays in STAT medications • Engaged interdisciplinary Lean Sigma team to reduce waste and improve consistency of process • Intervention: Add 45 frequently ordered STAT medications to the medication Pyxis on every unit. 43 Armstrong Institute for Patient Safety and Quality

Details in the differences… Time from “STAT Order Entry” to “Pharm Verification”: 70% reduction

Details in the differences… Time from “STAT Order Entry” to “Pharm Verification”: 70% reduction (p=0. 005) 44 Armstrong Institute for Patient Safety and Quality

Details in the differences… Time from “RN Med Retrieval” to “Pt Admin”: 77% reduction

Details in the differences… Time from “RN Med Retrieval” to “Pt Admin”: 77% reduction (p=0. 021) 45 Armstrong Institute for Patient Safety and Quality

Details in the differences… Pyxis to Non-Pyxis Orders: 26% reduction (~21 mins) 46 Armstrong

Details in the differences… Pyxis to Non-Pyxis Orders: 26% reduction (~21 mins) 46 Armstrong Institute for Patient Safety and Quality

Percent understanding patient care goals Poor Communication Among Care Providers Daily Goals 47

Percent understanding patient care goals Poor Communication Among Care Providers Daily Goals 47

Impact of Daily Goals on ICU Length of Stay Daily Goals 654 New Admissions

Impact of Daily Goals on ICU Length of Stay Daily Goals 654 New Admissions = $7 Million Additional Revenue

ICU Discharge Medication Errors • Goal: prevent medication errors in transfer orders • Measure:

ICU Discharge Medication Errors • Goal: prevent medication errors in transfer orders • Measure: Errors identified using discharge survey, audit 15 patients per week • Change: Medication reconciliation survey part of routine discharge process

Discharge Survey Audit

Discharge Survey Audit

Inpatient Falls Reviewed 15 months of fall data: – 90% of falls occurred on

Inpatient Falls Reviewed 15 months of fall data: – 90% of falls occurred on night shift, within 1 hour of change of shift, and on weekends. Fall Reason 10 9 8 7 6 Pre-Implementation (15 months, n=23) 5 4 3 2 1 0 Bed alarms Bathroom BSC/Urinal off Walking In/out of chair Restraints Fall prior to removed assess 52

s rm al a of f Ba th ro om BS C /U rin

s rm al a of f Ba th ro om BS C /U rin al W al ki In ng /o u R to es fc tra ha in ir ts re Fa m ll ov pr ed io Al rt lm o as ea se su ss re s in pl ac e d Be Fall Reason 10 9 8 7 6 5 4 3 2 1 0 Pre-Implementatin (15 months, n=23) Post-Implementatin (12 months, n=13) 53

Reducing Falls Fall Rate 10 Intervention started 8 7 6 5 4 3 2

Reducing Falls Fall Rate 10 Intervention started 8 7 6 5 4 3 2 Oct-10 Sep-10 Aug-10 Jul-10 Jun-10 May-10 Apr-10 Mar-10 Feb-10 Jan-10 Dec-09 Nov-09 Oct-09 Sep-09 Aug-09 Jul-09 Jun-09 May-09 Apr-09 Mar-09 Feb-09 Jan-09 Dec-08 Nov-08 Oct-08 Sep-08 Aug-08 Jul-08 May-08 0 Jun-08 1 Apr-08 Falls per 1, 000 Patient Days 9 NDNQI 10 th Percentile Fall Rate (Falls per 1000 patient days) Baseline Fall Rate 2. 92 falls/1000 pt-days Post-Intervention Fall Rate 2. 10 falls/1000 pt-days Incidence Ratio 0. 72 (P value = 0. 35) Relative Risk Reduction 28% 54

% of respondents within an ICU reporting good safety climate Safety Climate- Culture of

% of respondents within an ICU reporting good safety climate Safety Climate- Culture of Safety Survey

Culture of Safety- WICU/SICU

Culture of Safety- WICU/SICU

Culture of Safety- WICU/SICU

Culture of Safety- WICU/SICU

"Needs Improvement“ Statewide Michigan CUSP ICU Results • Less than 60% of respondents reporting good safety climate =“needs improvement” • Statewide in 2004 84% needed improvement, in 2006 41% • Non-teaching and Faith-based ICUs improved the most • Safety Climate item that drives improvement: “I am encouraged by my colleagues to report any patient safety concerns I may have”

% of respondents within an ICU reporting good teamwork climate Teamwork Climate Across Michigan

% of respondents within an ICU reporting good teamwork climate Teamwork Climate Across Michigan ICUs The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient care No BSI = 6 months or more w/ zero No BSI 21% No BSI 31% No BSI 44%

 % reporting positive teamwork climate Teamwork Climate & Annual Nurse Turnover High Turnover

% reporting positive teamwork climate Teamwork Climate & Annual Nurse Turnover High Turnover 16. 0% Mid Turnover 10. 8% Low Turnover 7. 9% © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011

Michigan Keystone ICU N Engl J Med 2006; 355: 2725 -32; BMJ 2010; 340:

Michigan Keystone ICU N Engl J Med 2006; 355: 2725 -32; BMJ 2010; 340: c 309. Armstrong Institute for Patient Safety and Quality 61

National On the CUSP: Stop BSI n=1, 821 teams from 1, 081 hospitals Armstrong

National On the CUSP: Stop BSI n=1, 821 teams from 1, 081 hospitals Armstrong Institute for Patient Safety and Quality 62

National On the CUSP: Stop BSI Participating Adult ICUs cohort 1 -5 n=1, 292

National On the CUSP: Stop BSI Participating Adult ICUs cohort 1 -5 n=1, 292 ICUs 29% of ICUs in U. S. Estimated: 294 -613 deaths saved $89. 9 - $238. 4 million excess costs averted Armstrong Institute for Patient Safety and Quality

Michigan Keystone ICU 100 80 60 40 20 30 28 - 27 25 -

Michigan Keystone ICU 100 80 60 40 20 30 28 - 27 25 - 24 22 - 21 19 - 18 16 - 15 13 - 12 10 - 79 46 03 In t er ve nt io n e 0 Ba se lin % Percent of ventilator days where patients received all five therapies Quarterly Composite Ventilator Bundle Adherence Over Time (Months) Infect Control Hosp Epidemiol. 2011 (in press)

Michigan Keystone ICU Infect Control Hosp Epidemiol. 2011 (in press)

Michigan Keystone ICU Infect Control Hosp Epidemiol. 2011 (in press)

Leading Change One of most common leadership mistakes is expecting technical solutions to solve

Leading Change One of most common leadership mistakes is expecting technical solutions to solve adaptive problems…. Heifetz, Leadership Without Easy Answers (Cambridge: Harvard University Press, 1994) 66

CUSP is a Continuous Journey • CUSP is a marathon not a sprint •

CUSP is a Continuous Journey • CUSP is a marathon not a sprint • Ask staff at least every six months how the next patient is going to be harmed and invest the time and resources to reduce this harm • Learn from one defect per quarter and share lessons learned • Implement teamwork tools that best meet the teams needs

Acknowledgements • Sallie Weaver, Ph. D • Sean Berenholtz, MD, Ph. D • Lori

Acknowledgements • Sallie Weaver, Ph. D • Sean Berenholtz, MD, Ph. D • Lori Paine, MS, RN • Paula Kent, MSN, MBA, RN • Peter Pronovost, MD, Ph. D and The Armstrong Institute for Patient Safety & Quality 68 Armstrong Institute for Patient Safety and Quality

References • • Andrews LB, Stocking C. An alternative strategy for studying adverse events

References • • Andrews LB, Stocking C. An alternative strategy for studying adverse events in medical care. The Lancet. 1997; 349(9048): 309 -313. Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Critical Care Medicine. 1995; 23(2): 294 -300. Leape LL, Cullen DJ, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999; 282(3): 267 -270. Pronovost PJ, Dang D, Dorman T, et al. Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery. Eff Clin Pract. 2001; 4: 199 -206. Tucker AL, Edmondson AC. Why Hospitals Don’t Learn from Failures: Organizational and Psychological Dynamics that Inhibit System Change. California Management Review, 2003 ; 45(2): 55 -72. Reason J. Human Error. Cambridge, UK: Cambridge Univ Pr; 1990. Bagian JP, Lee C, et al. Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. Jt Comm J Qual Improv. 2001; 27: 522 -32. • Pronovost PJ, Holzmueller CG, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf. 2006; 32(2): 102 -108. • Pronovost PJ, Wu Aw, et al. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Int Med. 2004; 140(12): 1025 -1033. • Vincent C. Understanding and responding to adverse events. New Eng J Med. 2003; 348: 1051 -6. • Wu AW, Lipshutz AKM, et al. The effectiveness and efficiency of root cause analysis. JAMA 2008; 299: 685 -87. • Berenholtz SM, Hartsell TL, Pronovost PJ. Learning From Defects to Enhance Morbidity and Mortality Conferences. Am J Med Qual. 2009; 24(3): 192 -5. © JHU and JHHS, 2011 69