Brian Kaminski

Brian Kaminski, DO, is vice president of Quality and Patient Safety and Patient Safety Officer at ProMedica (Toledo, Ohio) and Medical Director of the Emergency Department at ProMedica Toledo Hospital.

Dr. Kaminski became vice president of quality and patient safety and patient safety officer at ProMedica in 2013. During his tenure, he has implemented safety coaches at all ProMedica acute care locations and helped implement the Agency for Healthcare Research and Quality's CANDOR process, a road map for timely response to unexpected patient harm events. He also established Toledo Talks sessions, through which employees can share results of serious safety event investigations and work to implement lesson learned from root cause analyses. In 2015, Dr. Kaminski became a certified professional in patient safety through the National Patient Safety Foundation.

Their nominator said: “ProMedica HealthSystem has deliberately declared its intent in becoming a zero events of harmorganization. Starting in 2013 steps have been taken to improve the culture ofsafety across the ProMedica system. Special teams have been formed to quantifyand improve the number of serious safety events. In the last three years thenumber of serious events has decreased by approximately 65% and the AHRQ surveyhas shown positive improvements in all 12 domains.

ProMedicaCulture of Safety Milestones

ProMedica is committed to keeping patients,families and employees safe from harm.

At ProMedica, we are committed to keepingour patients, families and employees safe from harm. To do this, everyone usesspecial tools that improve our ability to maintain a safe environment. OurError Prevention toolkit serves as a reminder of specific techniques that canhelp reduce harm and ensure a high level of safety, quality and service to ourpatients.

Strategy

At ProMedica, we have made safety, quality and service excellence a strategic priority for the entire ProMedica Care Experience. We believe that creating excellent experiences directly connects with our mission of improving your health and well-being.

Culture of Safety Fundamentals

One of the most important cultural components of safety relates to the organization’s non-punitive response to error. It is our belief that the health care workforce is composed of well intentioned, well-prepared people in a variety of roles and clinical disciplines who do their best every day to ensure that patients are well cared for. It is from this mission of caring for people in times of their greatest vulnerability and need that health care workers find meaning in their work, as well as their experience of joy. It is our goal to shape safety culture through management practices that demonstrate a priority to safety and compassionately engage the workforce to speak about and report errors, mistakes, and hazards that threaten safety - their own or their patients. We do not feel that organizational learning and improved reliability in care delivery can be achieved by punishing people for normal human errors.

One measurement tool that can provide anassessment of this cultural attribute can be obtained by simply surveying thestaff. On an annual basis, we survey our workforce on their perception ofProMedica’s deployment of a non-punitive response to error. We ask our staff ifthey feel “their mistakes and event reports are held against them and thatmistakes are not kept in their personnel file.”

As a result of improving the way we respondto errors we have seen a dramatic increase in the number of events reportedacross our system, thereby allowing us to investigate these events and fixsystem failures that could lead to a similar event in the future. (See figure1).

A more detailed view of our Serious SafetyEvent Rate shows a 55% improvement in our rate of harm from our peak in 2015 toour current state in October of 2018. (See figure 2).

While there are many factors thatcontribute to an organization’s overall culture of safety, we feel that usingthe proxy of “Nonpunitive response to error” is a fairly easy and accuratemeasurement tool to determine how likely errors are to occur through theexperiences of the workforce.

Numerous tools and techniques can beapplied to create safer environments by reducing power distance and authoritygradients that typically exist in a hierarchy. One such tool that we use atProMedica involves empowering all staff members to speak up for safety. Infact, we feel that it is so important we have created a phrase that we expecteveryone in the organization to understand and adopt a nonpunitive responsewhen it is spoken. Our phrase is: “I have a concern.”

When this phrase is used, our hierarchiesare suspended, the work stops and the team responds by addressing the concernbefore moving forward. Although this may seem trivial, it allows for lesservoices in the organization to be heard and removes much of the fear andintimidation that can be associated with speaking up for subordinates withinthe organization. Importantly, there is no punishment for being wrong in thesecases. The work simply proceeds after the concern is resolved, whether or notthe individual was correct or incorrect in their assessment.

Following you will see two stories thathighlight some of our efforts in action. The act of capturing and sharing thesestories across our system plays a vital role in continuing to promote oursafety culture.

L&DNurse Prevents Medication Error

Recently, while on duty in the ProMedicaToledo Hospital (TH) Labor & Delivery unit, Val Olson, RN employed ErrorPrevention techniques to keep her patient from harm. She was retrieving anintravenous preparation of Pitocin for her laboring patient. Pitocin is amedication commonly used in L&D to help some patients progress in theirlabor. At TH, Pitocin should come in a 500 ml bag of lactated ringers (LR) with30 units of Pitocin added. These preparations are prepared in pharmacy and thenstocked in the Pyxis machine in L&D, so that they are readily available tothe staff there. When Val got a bag of Pitocin from the Pyxis, however,something didn't look right.

The scanning label, which pharmacy applies,clearly stated “Pitocin 30 units in 500 ml LR.” However, as Val looked moreclosely, she realized what had set off her internal alarm. This preparation wasmixed in a solution of D5LR instead of an LR solution. D5LR is a dextroseenriched IV solution which is different from standard LR. If Val had notnoticed this subtle difference on the original packaging and taken this bag ofPitocin to the patient's room and scanned it, there would have been no warningbecause the scanning label would have matched the physician order.  The simple human error which occurred inpharmacy would have made it through the barriers we put in place and reached ourpatient. As soon as Val discovered the error, she alerted pharmacy. DougDremann, RPh, TH Pharmacy Director, and his staff worked quickly to inspecttheir stock and found that there were no other mislabeled IV preparations inthe pharmacy stock nor in L&D.

So,why is this story important?

Thank you Val and Doug for maintaining apersonal commitment to the safety of our patients!

IRNurse Speaks Up for Safety

Deb Hilton, an Interventional Radiologynurse at ProMedica Toledo Hospital, was reviewing cases to prepare for thecoming week. While doing so, she noticed that one patient, scheduled for aliver biopsy, already had a Magnetic Resonance Cholangiopancreatography study(MRCP) performed. An MRCP is a non-invasive study which yields very detailedimaging of the liver, pancreas, gall-bladder, bile ducts, and pancreatic duct.Deb's experience told her that, depending on the results, the MRCP may havealleviated the need for a liver biopsy. Once she viewed the results, she feltstrongly that the patient might not need the more invasive liver biopsy thathad been scheduled. Deb escalated her concern to both the IR physician, Dr.Zakaria Assi and the ordering physician. After reviewing her findings withthem, it was determined that the liver biopsy was not needed.

So,why is this story important?

This story highlights the challenges incoordinating care for our patients in a healthcare landscape that has grownincreasingly more complex. With medicine becoming ever more specialized andmultiple physicians involved in the care of our patients, we must recognize weare prone to these types of errors. It is certainly possible that this errorwould have been discovered at another point, but Deb realized she might havethe opportunity to keep it from reaching the patient right now, and thisspurred her to action. At the very least, Deb saved our patient from days ofworrying about the procedure and the inconvenience of having to show up for it,not to mention the very real possibility of actually enduring the unnecessaryprocedure.

Thank you Deb for speaking up and for your commitment to safety! Thanks also to the physicians involved for hearing Deb's concern and ensuring that the most appropriate plan of care was realized.

Originally published in Issue 1, 2019 of MTM Magazine.