CHPSO July newsletter
CHPSO Patient Safety News logo

July 2013
Download PDF

In this issue:

Workarounds and Resiliency on the Front Lines of Health Care

Recent research suggests that hospital nurses experience an average of one “operational failure” per hour that results in time taken away from patient care. To put this into perspective, a nurse spends an average of 33 minutes per 7.5 hour shift on correcting operational failures in order to acquire the correct supplies, working equipment, or overcome communication barriers. Other health care professionals experience these operational failures, too. The cumulative time spent tracking down necessary items and information becomes staggering.

How do health care professionals manage to continue to provide necessary patient care in spite of these failures? By creating workarounds. In fact, workarounds are part of health care's culture. They are a source of organizational resilience: the ability to improvise with materials at hand to create a solution to an unexpected problem or situation. Sometimes the workaround is better than the existing procedure, but unfortunately, it is rarely shared or used to replace the dysfunctional process. In these cases, organizations do not learn and share this information to provide overall improvement because staff do not report the original problem to leadership.

There can also be unintended consequences from workarounds. Health care professionals often create a workaround to address an immediate issue but do not take additional steps to prevent recurrence or assure that the workaround does not compromise patient safety. For example, staff may repeatedly work around safety-related warnings while ordering medications that may be out of the recommended range rather than consulting the pharmacist.

What can organizations do to overcome a workaround culture?

Management should encourage employees to not only report recognized problems, but offer solutions. This behavior can be fostered by publicly recognizing and rewarding “good catches.” Staff need to see that you are committed to addressing the reported concerns or issues. Otherwise, they will ask themselves, “Why should I take the time to report this problem if no one is going to do anything about it?” Leadership must resolve identified failures, provide feedback to staff about the actions taken, monitor that the solution works, and resolve any unintended consequences. Health care organizations have to build-in capacity in both time and resources to address these concerns.

Another way organizations can avoid the creation of workarounds is by involving frontline staff in the development of policies and procedures, environmental design and set-up, and when choosing new equipment. These decisions are often made at a management level without the critical input from the personnel who are directly involved.

Tucker, A. April, 2013. Workarounds and Resilience on the Front Lines of Health Care. AHRQ WebM&M: Morbidity and mortality rounds on the web.

Transparency: Patients

Transparency: 5 types, Patients highlighted

In last month’s CHPSO Patient Safety News, we discussed the five targets of transparency: patients, coworkers, the organization, other organizations, and the public. A pdf version of that article is available at For each of these targets, there are specific practices that maximize the benefit to patients, providers and other stakeholders, and we will discuss these in this and future articles. Today’s focus is the patient.  

It is a moral imperative to inform patients when they are harmed, even when harm is minor or accidental. However, most providers are neither inherently comfortable nor necessarily skilled at providing what the patient wants and needs most:

  • Disclosure of all harmful errors
  • An explanation as to why the error occurred
  • How the error's effects will be minimized
  • Steps the physician and organization will take to prevent recurrences

This discomfort is partly due to the intense sense of shame a provider has when an error occurs. Historically, providers have held themselves at fault for any error, even those that, on careful review, are found to be the result of normal human performance, not negligence. Widespread application of human factors-based event investigations, e.g., the “Just Culture algorithm”, can help providers separate error from automatic self-blame.

A second part of this discomfort comes from the concern that transparency invites lawsuits. There is the concern that words of apology and concern will be misrepresented or misunderstood. The evidence to date counters that concern: organizations with broad disclosure policies tend to report decreased liability expenses—and many of the liability settlements are quicker and smaller, benefitting all parties. However, poorly performed attempts at apology can cause misunderstandings or misinterpretations, pointing out a benefit of disclosure training.

Training people on how to compassionately and accurately inform patients provides needed skills and helps reduce the anxiety that is natural in such emotionally charged situations. There is a burgeoning body of literature and advice on this topic. Our partner, ECRI Institute, provides a comprehensive summary (as of 2008, but still valid) describing some of the steps to take to establish an effective disclosure program.  The AHRQ Patient Safety Network provides more resources.

Not only is disclosure to patients the right thing to do, it is required in many circumstances. For example, within the California mandatory adverse events reporting law, H&S 1279.1(c) states that the patient (or party responsible for the patient) shall be informed by the time the report to the state is made. Notification is required regardless of the extent of harm. CHPSO has identified, in reviewing the state’s adverse event investigations, that presence or absence of patient notification is one factor differentiating events closed without findings from those that result in adverse action by the state.

Other entities also require or strongly encourage disclosure. For example, the Joint Commission standard RI.1.2.2 states that patients are to be informed about the outcomes of care, including unanticipated outcomes. The AMA code of ethics (Opinion 8.121) requires members to disclose when an unintended act or omission, or a flawed system or plan, harms the patient. Both organizations describe what should be included in the disclosure.

In summary, a well-organized and planned practice of patient disclosure benefits all involved and helps move us further on the path towards elimination of preventable patient harm.

For more information

AHRQ PSNet literature collection:

ECRI Institute Executive Summary: Disclosure of Unanticipated Outcomes:

Just Culture:

PDF version of this article:

Lessons Learned

Why Are Some Organizations Reluctant to Participate in a PSO?

Patient Safety Organizations (PSO) were created by the federal Patient Safety and Quality Improvement Act of 2005 (PSQIA) to encourage health care providers to share and learn from a collective pool of data that is legally protected from discovery during litigation. Many organizations with a mature safety culture understand the value of participating in a PSO, but unfortunately some organizations are still not on board. This reluctance has been a surprise to many in the patient safety field, but there may some misunderstandings about PSOs that are preventing organizations from benefitting from participation.

Is this just another fad?

There has been tremendous work focusing on quality and patient safety over the past decade. Those who work in quality, patient safety, and risk management have had to adjust to the constant change in improvement models over the years, and have become skeptical about adopting new models, ideas, or processes until they have been proven to be lasting and effective. This is understandable because jumping from one change model to another is not effective. It is recommended that an organization adopt a standard change model and bring in principles from other models as appropriate. For example, a hospital may primarily use a lean six sigma model for performance improvement, but use a rapid cycle PDSA (plan, do, study, act) when improving a process with multiple steps.

Organizations should view PSO participation as a way to augment their current processes, not replace. When developing improvement strategies, organizations often question, “Is this a problem for anyone else? If so, what are they doing about it?” PSOs offer that safe platform for sharing information and best practices in a protected environment.

CHPSO offers lessons learned through Patient Safety News as well as providing feedback to individual member organizations. Educational webinars are offered at least monthly to provide valuable information and instriction in ways organizations can build a culture committed to patient safety.  The CHPSO website has a "useful tools" section with guidelines and forms shared by other members to assist in causal analysis. This resource center will soon contain additional "ready-to-use" information.

Skeptical about legal protections

Some organizations question the strength of the protections promised by the PSQIA. Some recent court cases have attempted to challenge these protections and the outcomes have been reassuring to many. A Kentucky trial court in late 2011 ruled that the federal PSQIA protections superseded state peer-review law and that patient safety work product (PSWP) that had been reported to a PSO was protected from discovery. The plaintiff attorney requested the disclosure of various documents, including a Root Cause Analysis (RCA). Under state law, the documents would have been discoverable because they were not subject to attorney-client privilege. For full details of this ruling and other cases, visit the “Legal references” section of the CHPSO website.

This is one of the first cases in which a state court upheld PSQIA protection and will likely set precedence for future challenges.

Overwhelmed with data reporting

With so many other mandatory reporting requirements, organizations may think that voluntary reporting to a PSO is too much of a burden. In addition, patient safety and risk management professionals are busy responding to the events within their institution and may not have the time or resources for external reporting. It is easy to overlook the ways PSO participation may actually save on time & resources.

By learning from others, facilities can standardize and streamline processes that will make them more efficient and productive, as well as provide safer and better quality care to their patients. Instead of spending time responding to events that have already occurred, patient safety, quality, and risk professionals can devote their efforts to prevention.

CHPSO is working with incident reporting vendors to encourage more automation in the PSO reporting process. Some systems, like Midas, have already successfully developed these modules and are working to remove as many manual steps in the process as possible.

Not mandatory…Yet

Reporting of event data to PSOs was originally designed to be voluntary. However, some agencies already understand the value of learning from the data captured by PSOs. The Health Information Technology for Economic and Clinical Health (HITECH) Act and the Office of the National Coordinator for Health Information Technology (ONC) encourage reporting of health IT related safety events through PSOs, rather than create another federal agency to collect, aggregate, and analyze this information.


Not Just Adverse Events: The Bigger Picture from Four Years as a PSO. August 2012. Risk Management Reporter, ECRI Institute, Vol. 31, No. 4)

Causal Analysis Learning Series

CHPSO continues the Causal Analysis Learning Series with “Identifying Contributing and Root Causes” on July 8, from 10 to 11 a.m.

When it comes to understanding broken processes, we need to better understand the environment in which we work and the impact of human factors and at-risk behavior. We’ll review various tools and techniques used to successfully identify and communicate contributing and root causes of adverse events.

We are fortunate to be joined by Steven Savage, Ed.D., Quality Improvement Network Facilitator, California Hospital Engagement Network (CalHEN) and Kassie Waters, Director of Quality Management, Marshall Medical Center.


This call is for members only.  Registration is required and can be found at Please note that a website member account is a requirement to sign up for member-only webinars.

Registrants will receive an email a minimum of 24 hours before the event. Members registering within less than 24 hours of the event should contact CHPSO for participation information at (916) 552-2600.

Continuing Education

Provider approved by the California Board of Registered Nursing, Provider #CEP 16084, for 1.0 contact hour.

Full attendance, completion of online survey, and attestation of attendance is require to receive CE for this webinar.  CE are complimentary for registrants.

Past webinars

Content from the first two webinars, along with other past webinars, is available to members at

Who’s Behind That Mask in Your OR? Managing Vendors in the Operating Room

CHPSO / ECRI Webinar

July 15, 2013, 11:30 a.m.–12:30 p.m.

Register for this event

Sales representatives provide nurses, physicians, and technicians with some of the information they need to keep up with the changing technology of surgical instrumentation and equipment. But when sales representatives are brought into the operating room or other procedural areas, they may become a hindrance, a safety hazard, or the cause of a lawsuit if they do not understand OR protocol or if the hospital fails to delineate its expectations.

  • Have you been challenged with managing vendors in your organization?
  • Do you have support from your surgeons and proceduralists?
  • Has your hospital developed successful processes or is vendor management presenting a challenge?

This user group will share effective strategies for managing vendors in your operating room and other procedural areas.

This call is for members only. Registration is required and can be found at Please note that a website member account is a requirement to sign up for member-only webinars.

Registrants will receive an email a minimum of 24 hours before the event. Members registering within less than 24 hours of the event should contact CHPSO for participation information at (916) 552-2600.

Useful Tools Now at

CHPSO is excited to help member hospitals collaborate by providing a resource center for sharing effective tools that can be used to enhance your patient safety efforts. This resource center, called Useful Tools, is located on the CHPSO website and can be found in the Member Resources section or at Please note that a website member account is a requirement to access this page.

Thank you to St. Joseph Health for providing their event investigation tools.

If you have tools or guidelines to share, please contact Rhonda Filipp, Director of Quality and Patient Safety at CHPSO.

Submitting Reports: Portal Access and Use


July 26, 2013, 10:00 a.m.–11:00a.m.

This webinar is designed to assist those members who are not submitting data to CHPSO through the CHPSO/ECRI portal, as well as for those members who are not clear about how to access other member services and resources. Attendees will learn:
  • How to access the CHPSO/ECRI portal and submit your reported data
  • How to upload RCAs for critique
  • How to submit customized research requests
  • Resources available to Member’s Only sections of the CHPSO website


This call is for members only.  Registration is required and can be found at Please note that a website member account is a requirement to sign up for member-only webinars.

Registrants will receive an email a minimum of 24 hours before the event. Members registering within less than 24 hours of the event should contact CHPSO for participation information at (916) 552-2600.

CHPSO Email Outage

CHPSO experienced sporadic email difficulties between June 28 and July 3.  If you emailed any CHPSO account (<name> or sent a message through the CHPSO website between June 28 and July 3 and have not heard from us, please contact us again.  We apologize for missing your message and look forward to helping you.

Reporting System Vendor Readiness Update

CHPSO continues to work with event reporting system vendors to develop simple ways of transferring event data to CHPSO. This is a status report of the vendor’s progress.

Hospitals are successfully sending data electronically

RL Solutions (but not from any California hospitals yet)

Vendors are testing transmission


CHPSO can help

Contact us if you have any questions about electronic event submission or need assistance with a vendor’s product.

Upcoming Patient Safety Events

California Hospital Patient Safety Organization

Unless noted, all CHPSO events are for members only. Members will receive an email a few days before each event with information on how to participate. All times are for the Pacific Time Zone. For more information, contact or call (916) 552-2600.
July 8
10–11 a.m.
Causal Analysis Learning Series: Identifying Contributing and Root Causes
(CHPSO Monthly Member Call)
July 15
11:30 a.m.–1:30 p.m.
Who’s Behind That Mask in Your OR—Managing Vendors in the Operating Room
(CHPSO / ECRI Webinar)
July 26
Submitting Reports: Portal Access and Use
(CHPSO / ECRI Webinar)
August 12
10–11 a.m.
Causal Analysis Learning Series: Developing and Implementing a Corrective Action Plan
(CHPSO Monthly Member Call)

Hospital Council of Northern and Central California

July 17
12–1:30 p.m.
The Use of Social Media by Hospitals – What You Should Know Part 1: Possible Uses and Legal Risks of Social Media Use by Hospitals
July 24
12–1:30 p.m.
The Use of Social Media by Hospitals – What You Should Know Part 2: Best Practices, Policies and Procedures for Social Media Use by Hospitals
August 1
12–1:30 p.m.
Effective Purchasing of Hospital Health Information Technology Part 1: The EHR Incentive Program and Other P4P Basics
August 8
12–1:30 p.m.
Effective Purchasing of Hospital Health Information Technology Part 2: Mechanics of Procuring Health IT

Hospital Association of Southern California

July 16 Southern California Patient Safety First Collaborative meeting, Hyatt Regency, Orange County. Please contact Julia Slininger for more information.

Hospital Association of San Diego and Imperial Counties

For more information visit or contact Alicia Muñoz.

July 12
11 a.m.–3:30 p.m.
HASD&IC Quality and Patient Safety Program Networking lunch, presentations and workshops.  Speakers from the Joint Commission TST, Patient Safety First, Hospital Engagement Network and Hospital Quality Institute.
Location: Handlery Hotel

Copyright © 2013 CHPSO, all rights reserved.