Annie's Story: How A System's Approach Can Change Safety Culture

[@kellywise3251]

I also think this is a great story, but still notice that the initial conclusion drawn was that the nurse was at fault, and the disciplinary action was initiated. Even if the end result was a team approach to investigate the human factors involved, the damage to this nurse was done. The rest was back pedaling and service recovery for this employee. What will it take to restore her and other employees' trust that knee jerk reaction that blames the employee for what are systems issues will not happen again.

[@MedicalHumanFactors]

Spot on, and in fact, that's why we made the video. This happened in 2011, and was part of the impetus to change how adverse events were handled. The video was created as a training tool for leadership, to help demonstrate the detrimental effect of misplaced blame.

[@matthewbishop9255]

Why does it matter? The correct outcome was achieved. 99.9999999% of the time, it’s human error... How often do medical systems designed to be flawless malfunction? I’ve never seen it. I’ve only heard of it a time or two. The nurse was vindicated, no harm no foul.

[@oliviatran4239]

@@matthewbishop9255 Do you really think vindication is good enough? And no harm, no foul to the nurse?

[@rachelgooden9981]

This!

[@kellysmith7629]

What a tremendously powerful story. Annie, your courage to tell it says so much. We are glad you are here.

[@sicario91]

It's not uncommon to be immediately blamed by nurse managers who don't respond, but rather react.

[@maximussarcasticus1312]

"They reversed the discipline" Which is awesome. Congrats to them. Sadly the damage has been done. Do that before you discipline and you've got it. In other words, do the process, then seek corrective actions. By the way, was HR disciplined for their mistake of suspending before they had all of the information?

[@charleskenney6545]

Great story. Congratulations MedStar for your transparency in this matter. It is so important that increasing numbers of provider organizations understand the critical importance of systems thinking vs. blaming individuals.

[@oliviatran4239]

It is too generous to say congrats to this system while damage to this nurse has done...

[@aidasol269]

Thank you for sharing MedStar. Great teaching tool for Just Culture!

[@sailingonwaves]

I fail to see how this represents a "Just Culture". Damage was done to that nurse. She deserves ample fiscal compensation or career promotion after the psychological trauma you forced her to endure. Shame on a system that immediately suspends a nurse for an equipment error. No, the investigation did not need to be done unless it was a repeat offense of the same exact problem with the same nurse. This was a one-off occurrence with this nurse according to the story. Nurses are abused because we are traditionally women. Nurses are underpaid because we were originally only women. Rise and say no more! Would a male nurse get the crass treatment Annie got? I doubt it. Nurses: if you're ever approached in a scenario like this challenge that day's staffing ratios, missed legal breaks due to workload, scheduling malpractices, and poor administrative monetary allocation for new equipment on the unit. THEY ARE RESPONSIBLE FOR SETTING THE BEST STAGE FOR US TO WORK IN- this is not our responsibility to absorb.

[@beatricesiaw8776]

There are worse nurses than her.

[@rachelgooden9981]

She’s still traumatized. Poor thing. So brave and helpful of her to speak up and do this video to contribute to the Just culture movement

[@QIClinic]

This is a great film - so many lessons for so many people in healthcare organisations

[@jackieharts6944]

Wow that is crazy. We do not realize how much we depend on our equipment that we forget sometime they can be incorrect. This can really happen to anyone.

[@kathleencolwell8947]

In my experience, “high” and “low readings on these glucometers require a venous blood draw for a BMP or chem 7. Was this ever done?

[@beatricesiaw8776]

Critical thinking is very important in medicine. Don't just take what you're given.

[@davidhughstewartdavid5190]

Very illuminating. It has enhanced my understanding as a hospital trust governor.

[@rachelgooden9981]

Im so happy I came across this video from Future Learn. I have subscribed and shall binge watch the videos on here

[@dantemlima]

I am a medical doctor. I came here because I am reading Zero Harm. The nurse should not have been disciplined in the first place for making an error in good faith. At the time, it was immediately apparent that a technical fault was the cause of the misconduct. It is hypocritical that the same staff who harshly and summarily judged her are now sitting for the camera to take credit for the change in hospital culture. RN Marino even tries to justify his department by saying that they "did not fully understand the piece of equipment and the message that it displayed." This should have been the reason for immediately excusing Nurse Annie from being responsible for the serious adverse event. The moral harm done to her is irreparable.

[@sortmta8426]

Equipment can be wrong, a friend of mine who is part of a mountain rescue team was telling me that a navigation error was caused on one occasion and even though people felt it was wrong they still trusted the equipment! several people took compass bearing with different compasses and all got the wrong bearing, it appears that the team had all recently been issued with new gloves/mittens for cold weather and the mitten cover had a magnetic catch which was throwing the compass readings out. as the weather was coming in and everyone was getting stressed and they all reverted back to system 1 thinking (auto pilot what they knew and not questioning equipment). The lesson here is whenever you change part of a system its important that its integration into the system is checked to ensure it doesn't have an effect on the rest of the system.

[@jennyhughes4474]

Thank you for helping to make healthcare safer. Sometimes too much reliance is put on machines/tech when listening to the patient & believing us is too often not done; it's good you removed the discipline from the nurse but it sounds like she should never have been treated in this way = too hasty to blame a person instead of machine malfunction? Saying this, there ARE cases where individuals ARE personally responsible for errors and must be held accountable & lessons learned and hopefully better systems designed to prevent human factors/errors & reliable tech that's regularly tested will help too.

[@seifalah0626]

This is a great example of system errors. However, i'm a little surprised that the hospital would not double check with a lab draw or more definitive measurement tool. Even during a code event the physician manually checks for a pulse vs simply looking at the EKG. I would expect that the hospital would do the same in these types of events

[@sheitman19]

We always get a lab draw whenever the glucometer says "high" or "low"

[@Vista9889]

Totally agree. My thing is, what was the dosage of insulin based on? After repeat test, showed the same result, a different glucometer should have been used and a serum sent to lab. I think there's some RN fault here, but I'm glad to see that a root cause analysis was done and that "just culture" prevailed. Lesson learned, utilize assessment and critical thinking skills, and follow P&P.

[@carolmccarthy3818]

My ma was a nurse from ww2 and such compassion, caring& devotion- like nuns they do the work90 percent- its a calling& they must have paitience having to put up with megomaniacs and self proclamed demi gods. Not all docs, but a lot. Brian

[@hellojuneau8917]

Never solely rely on technology. Sure it is convenient but you're dealing with real lives here and if you feel something is possibly wrong, check manually for other cardinal signs of hypoglycemia.

[@danfoulds]

Thanks for sharing this. I will use it in a class on HRO's for an upcoming regional HEMS safety conference, and for AMRM training in general.

[@medstarhealth]

You're welcome, Daniel! Have a great day.

[@MedicalHumanFactors]

How did it go?

[@Bill.R.124]

Glad they recognized their inappropriate, heavy-handed approach to the nurse. How was the nurse to know that the glucometer was malfunctioning? What did the policy say to do? Usually, a simultaneous venipuncture, sent to the lab, is required for confirmation. The question is, how often is the lab or Biomed doing routine maintenance/evaluations of the POCT devices? Were there reports of errors r/t to the manufacturer?

[@BethBoynton]

Kudos to Annie for hanging in there and the team for ultimately treating this as a systems’ problem. As this short dramatization shows, good communication is essential for creating a culture where near misses are identified and reported: kzbin.info/www/bejne/l5TCh6OpqJ1joq8

[@annellewellyn459]

Very good story. Hopefully this approach is getting out....and we do respect professionals and not judge them on the surface but look at the situation.

[@MayaRaimondo]

We all have to remember to observe, ask & assess the patient when in doubt about the the equipment. They are awesome & expensive things, but that is all they are: equipment. L👀K at the patient and start using good judgment & assessment skills you worked so hard to learn. Safety & JUST CULTURE 👍🏼

[@judithelam317]

if you look closely at glucometer screen, it appears to say 'LO' behind the alert notice. Reading the alert notice, it simply indicates that lab value was critical result & if it should say hi, it means that glucose is greater than 600. Yes, the machine needs an improved design so that the actual value showing of 'Lo' was readily visible when the error screen came up. however, it seems that 'seeing' this same message for 3 or 4 or more testing results, someone should have noted the result being covered up..... Definitely an indication of a system error with unacceptable outcome...

[@Sheba_316]

Remember the meter shown here is part of reconstruction. What the nurse said was that the meter read Hi..

[@MedicalHumanFactors]

@@Sheba_316 the meter read LO. But indeed the nurse thought it read HI, because she could not see the LO or the HI (covered by the warning message), and the warning message contained the text "glucose > 600." This is the central cause of the error, resulting from the design of the device, the lack of guidance from the manufacturer on the safest wording for the alert, and unfortunate choices of wording that were made locally during implementation (with the right intentions).

[@anthonyandreola9147]

Thank you, going to recommend to my bosses that we use this video where I work.

[@medstarhealth]

That's a great idea, Anthony. You're very welcome.

[@jaremiemorales7715]

Can we use this video for a presentation, please?

[@laurie8102]

Should be no different many other things in life. Finding the reasons why it happens for then you’re understand how to resolve it for a better future for generations move forward for a better future

[@stephaniejepko3640]

This is a powerful story! I would love to show this as a training tool. Could the license be changed to a KZbin Creative commons license so I can download it?

[@MedicalHumanFactors]

email us and we'll be happy to send you the video. www.MedicalHumanFactors.net. --Terry Fairbanks

[@jamesthewatcher3932]

It's good to at least admit error and do everything to amend

[@jericstanford]

I would like to learn more about this situation, but on the surface just using the information presented in the video, was the laboratory and laboratory management involved at all in this investigation? What oversight of point of care testing did the laboratory have at the time and how has it been implemented since? Point of care testing is great because of the convenience, but laboratory testing is a very complicated matter and takes highly skilled and trained laboratory scientists to interpret results and ensure they are accurate. A quality point-of-care testing program ensures appropriate training of staff utilizing the equipment as well as periodic assessment of competency (staying up to date on training, policies, how-to, etc.). Yes, this was a poorly designed message presented by the device and easily misinterpreted. Proper training and policies could have mitigated this risk to some degree, but the message still had the potential for confusion and misunderstanding. Proper oversight of point-of-care testing can help identify such risks and implement safe-guards to try and prevent serious safety events. Nothing is 100% error proof, but can help. It is very commendable that they investigated properly and found the nurse was not at fault for misinterpreting a poorly designed message from the device.

[@mamaladybug3]

Feel so bad for the nurse 😢

[@chelseamiller8560]

I must be missing something....how was this ever the nurses fault? The glucometer was clearly malfunctioning. She rechecked the blood glucose level multiple times. I don't see how it was ever her fault at all. Are nurses to blame when our equipment fails?

[@Sheba_316]

Why wouldnt the management seek to understand first before automatically blaming the nurse??? As i listened i thought she was going to say they had a look at the glucometer and asked bio-engineers to look at it....rediculous. The result now is a nurse that is less confident in her practice..

[@medstarhealth]

Thank you for sharing your thoughts on Annie's experience. This story has stimulated conversation and created a paradigm shift regarding a just culture and systems approach. Fortunately, Annie’s story had a happy ending-management reversed its course, and we implemented a process improvement across our 10 hospitals. Thank you for watching and keeping the conversation going!

[@MedicalHumanFactors]

That's exactly the point of the video, and the message we're trying to convey. It's a story of why we don't do it this way anymore, hoping to influence others. The blame game is still quite prominent in healthcare. This leads to premature closure of the case, before proper learning has occured, which leads to ineffective mitigation, and repeat events. AND it reduces the open safety culture that would allow others to feel comfortable raising concern with leaders after they experience a near miss or error. It makes us less safe when we rush to discipline. This is what the just culture concept is meant to address. However, this does not mean that there is a lack of accountability. Even discipline is necessary somtimes, but if you take a step back, withhold judgment, event when it seems obvious, and spend some time doing a proper review (as in the IHI/NPSF RCA2 approach, or AHRQ's Candor approach, or the MedStar Event review method, you'll actually create a safer system over time).

[@josephlach4050]

I think this video demonstrates an over-reliance on technology. Just culture in healthcare organizations is important. However, all nurses should know the symptoms of hypoglycemia.

[@kinzierae]

well fatigue and weakness is a symptom of both hypo and hyperglycemia... so symptom assessment may not always be the best answer.

[@MedicalHumanFactors]

The aviation industry used to use "all pilots should know XYZ" as their primary safety approach. The last time they relied on that was around 1973, when they realized that safety critical operations need proper risk assessments, and where necessary they need system-focused design strategies to mitigate the inevitable human error. Especially in a complex environment such as healthcare, it's naive to rely on 100% consistent never-miss vigilance. This case is a great example. This nurse was exceptionally good, and the error occurred on a diabetes floor. She did know the symptoms of hypoglycemia. There were several contributing factors. Great example of why we need to ask questions before passing judgment.

[@sailingonwaves]

I think it is pretty easy to say this as a response @Joseph Lach when you don't know the holistic story. You don't know how many 12s Annie was scheduled in a row, you don't know the staffing ratios or the patient acuity that day, you don't know the interruptions she was experiencing during this. Also, please note that the patient was reinforcing the fact that they "know my body and I feel hyperglycemic". So do nursing a favor and jump off your high "everyone should know the s/s of...." horse. We aren't here for that.

[@scrapbookedmemories7736]

I wonder how many nurses go down because of the blaming culture that refuses to go Just Culture.

[@mamad778]

Nurse should have obtained a stat blood draw and utilized another glucometer.

[@NathanielOnYouTube]

The other glucometer would have displayed the exact same message. It wasn’t malfunctioning. The alert message was very poorly worded and set the RN up for confusion.

[@idahenry1]

sad

[@rachelgooden9981]

Oh crap! Oh no

[@yesen25]

manual glucose measurements are better than electronic devices

[@annadhaliwal822]

sorry but I have never heard of a "manual" glucose measurement?! Is there another way to measure BGL than using a glucometer?

[@MedicalHumanFactors]

It's not that simple--Both are susceptible to error. The primary cause of this technology-induced event is poor design of the human-machine interface, violating basic human factors/safety engineering approaches. It's not the presence of technology that is the issue, it's the lack of safety-driven design and implementation. See www.MedicalHumanFactors.net for more

[@suz3431]

Good grief, are you actually suggesting back to boiling down urine for sugar results????. People we live in the 21st century, tech is an adjunct to quality nursing care but if we can't rely on a healthcare system to provide working equipment well why bother even using it? The crawly sycophantic ingratiating manner that the hospital management used to cover their own mismanagement of a sentinel situation is disgraceful. I suppose you can acknowledge they went public with their sorry tale of systemic failure of due process in all number of arena's. Were people in HR and "suspended" for handing down such directives without properly accessing the facts in what was clearly a dereliction of duty on their part? I certainly hope they went beyond the"withdrawal of discipline" as rectification for the damage they did to that nurse's confidence and faith in the expectation of a provision of a safe supported working environment. Shame on you.

[@tracysmith1666]

You’re supposed to use the glucometer that the hospitals provide because they are (for the most part) connected to their charting systems. You have to verify the patient and then do the reading. It uploads that value (irt) to their chart as well as the person who obtained it. She would have been best off calling the physician then a stat blood draw like the glucometer told her to before doing anything else. I wouldn’t even know how to take a manual blood sugar.

[@exclaimhealthmedia2325]

😯

[@ololadearogundade2961]

The nurse was not treated fairly