Applying ‘just culture’ approach to perfusion may improve patient safety

SAN DIEGO — Implementing the “just culture” approach to clinical practice could allow health care professionals to identify and learn from human errors in medical care, subsequently improving patient safety, according to a presentation.

Dave Fitzgerald, MPH, CCP, clinical coordinator of the CV Perfusion Program at the Medical University of South Carolina, said human errors are an indication that there is a larger problem in the system. To identify the problem will require an investigation into why the actions that led to the error were taken in the first place.

“It has already been established by experts around the world that when we decide to punish people for mistakes, we are not fixing the problem, we are perpetuating it,” Fitzgerald said. “But we do not want people to be accountability-free. Just culture, by definition, tries to strike that balance between what is a blame-free vs. punitive environment to better understand what the circumstances are that led to the quality of that decision.”

Fitzgerald focused on the potential impact of just culture in the perfusion community. He said reporting human errors, even those that do not result in major injuries, is a critical component of a just culture environment. Errors that result in serious adverse events are required to be reported. However, findings from four surveys conducted by perfusionists between 1972 and 2010 show that few perfusion-related errors result in major injuries. For each major injury, an estimated 300 “near misses” that do not result in harmful incidents occur. Consequently, Fitzgerald said it will be important to identify and learn from these near-miss events.

“We can learn from our near misses to prevent the likelihood that a major hit occurs. But in order to do that, we need people to come forward and share those with us, so we can understand the quality of the decisions that were made or the precursors that were there prior to the event,” he said.

However, data from the Agency for Healthcare Research and Quality’s hospital survey on patient safety show that perfusionists are less likely to report near misses.

“I challenge our perfusion community to do better,” Fitzgerald said.

He encouraged perfusionists to take steps at their institutions to:

reward reporting;
ensure there is open communication among staff;
emphasize the importance of learning from mistakes;
share accountability; and
discipline employees fairly and consistently based on the circumstance and intentions.

When near-miss events are identified, the report can be implemented into a failure mode and effect analysis (FMEA), which providers can conduct to proactively assess the risk for major injuries. FMEA templates, he added, are publicly available on the Medical University of South Carolina website and can be customized to individual institutions.

“You can implement FMEA and track your progress,” he said. “Are you making your program safer? These are the types of things regulatory agencies love to see. This is our responsibility as patient safety advocates.” – by Stephanie Viguers

Reference:

Fitzgerald D. The “Just Culture” Approach to Perfusion Quality and Safety. Presented at: The Annual Cardiothoracic Surgery Symposium; Sept. 6-9, 2018; San Diego.

Disclosures: Fitzgerald reports no relevant financial disclosures.