CHPPC Module 12, Section 5: Maintaining Safety Culture Under Pressure
MODULE 12: CODE CARTS & EMERGENCY PREPAREDNESS

Section 5: Maintaining Safety Culture Under Pressure

This capstone section addresses the most challenging and most human aspect of crisis management. You have learned the protocols for managing a code blue. Now we will explore what holds it all together: the culture. The ultimate test of a team’s resilience is its ability to maintain a focus on safety when everything is going wrong. In this masterclass, we will discuss the principles of High-Reliability Organizations (HROs) and provide you with concrete strategies for fostering a culture of vigilance, psychological safety, and mutual support during a crisis.

5.1 The Nature of a Safety Culture: Beyond the Absence of Error

Understanding that culture is defined by the response to failure, not the avoidance of it.

A “Culture of Safety” is not a workplace that is free of errors. Human beings are fallible, and in a system as complex as a hospital, errors are inevitable. A true safety culture is defined by its response to those errors. It is an environment where individuals are not punished for making honest mistakes, but are instead empowered and encouraged to report them without fear of retribution, so that the organization can learn from the failure and make the system safer. Under the immense pressure of a code blue, a weak safety culture will crumble into one of fear and blame. A strong safety culture will become even more resilient, characterized by heightened communication, trust, and a collective commitment to protecting the patient.

Retail Pharmacist Analogy: The New Technician’s Dispensing Error

A new technician, working hard to keep up with the queue, accidentally fills a prescription with the wrong medication. There are two possible cultural responses.

A Punitive Culture: The pharmacist discovers the error at the final check and berates the technician in front of their peers. “How could you make such a stupid mistake?” The technician is written up. The result? The technician is now terrified of making another mistake, works slower, and will be highly unlikely to self-report any future near-misses. The system has learned nothing.

A Just Culture: The pharmacist pulls the technician aside privately. “Hey, I caught this error. Let’s talk about it. What happened here?” The technician explains they were rushing and the two bottles looked alike. The pharmacist then engages in a systems-level fix. “You’re right, they do look alike. Let’s move one of them and add a ‘look-alike, sound-alike’ sticker. Thank you for helping me find a way to make our system safer.” The technician feels supported, the system is improved, and trust is built.

Your role as a leader during a crisis is to be the champion of the Just Culture, even when the pressure is at its highest.

5.2 Lessons from the Cockpit: Principles of High-Reliability Organizations (HROs)

Applying the science of safety from industries where failure is not an option.

Healthcare has increasingly looked to other high-stakes industries—like commercial aviation and nuclear power—to learn how they achieve extraordinary safety records. These High-Reliability Organizations (HROs) achieve safety not by having perfect individuals, but by creating systems built on the assumption that failure is always possible. They build processes that can anticipate, detect, and contain errors before they cause a catastrophe. Let’s translate the five core principles of HROs to a Code Blue.

HRO Principle Definition Pharmacist in a Code Blue Application
1. Preoccupation with Failure A constant state of vigilance and a belief that the next error is always lurking. HROs are actively looking for the next potential failure point. Your Mindset: “I’ve handed off the epinephrine. What’s next? Probably bicarb or calcium. Is the IV access good? Let me double-check the concentration on this vial one more time, just in case.”
2. Reluctance to Simplify Resisting the urge to create simple explanations for complex problems. HROs dig deep to find the true root causes of a failure. Your Mindset: The patient isn’t responding to epinephrine. Instead of just pushing more, you ask: “Could this be hyperkalemia? A tricyclic overdose? Should we consider a different pressor?” You add pharmacological context.
3. Sensitivity to Operations Maintaining a deep, real-time awareness of the reality on the front lines (situational awareness). Your Mindset: You’re not just waiting for orders. You are listening to the rhythm being called, noting the time since the last drug was given, and observing the nurses to see if they are struggling to draw up a medication. You see the whole picture.
4. Commitment to Resilience Knowing that failures will happen, and therefore investing in the ability to contain those failures and recover quickly. Your Mindset: A nurse draws up a medication but is unsure of the dose. You immediately step in to verify the calculation before it’s given. You are the pre-programmed “Plan B” that catches the potential error and allows the code to continue safely.
5. Deference to Expertise In a crisis, decisions are made by the person with the most expertise, not the highest rank. Your Mindset: The code leader, a physician, asks for a drug you know is incompatible with the fluid running. You state clearly and respectfully, “Doctor, that drug is not compatible. We need to flush the line first or use a different port.” You are the medication expert, and in that moment, your expertise leads.

5.3 Leading with Safety in a Crisis: A Practical Toolkit

Actionable strategies for fostering psychological safety and vigilance under fire.

The principles of HROs are enacted through concrete behaviors. Your actions and words set the tone for the entire team. Under pressure, people are more likely to make mistakes and less likely to speak up. Your primary job is to counteract this by creating an environment of psychological safety.

Promoting Psychological Safety and Mutual Support

You can actively build a safety net of trust and communication with your actions.

  • Acknowledge the Stress: A simple statement like, “This is a tough situation, everyone is doing great work,” can lower the tension and build solidarity.
  • Invite Questions: Actively ask for input. “Does this calculation look right to you?” This signals that all input is valued and makes it safe for others to question you.
  • Model Fallibility: If you are unsure about something, say so. “I need to quickly double-check that compatibility.” This shows that it’s okay not to have all the answers and prioritizes safety over ego.
  • Promote Cross-Monitoring: Encourage the team to look out for each other. “We are all focused on different tasks. Please speak up if you see anything that concerns you, no matter how small.”

Tool for Action: Closed-Loop Communication

The single most important communication technique in any emergency is the closed loop. It is the bedrock of safe verbal orders and prevents errors from misheard instructions.

  1. Sender gives the message: (Physician) “Give one milligram of epinephrine IV now.”
  2. Receiver repeats the message back: (You or Nurse) “I am giving one milligram of epinephrine IV now.”
  3. Sender confirms the message was heard correctly: (Physician) “That is correct.”

This simple, three-step process eliminates ambiguity and ensures that the order given is the order being acted upon. You must rigorously model and enforce this practice for every medication during a code. It is the primary tool for creating reliability in a chaotic environment.

5.4 The “Hot Wash”: The Engine of Learning and Resilience

How to transform the lessons of a crisis into a stronger system.

The single most important activity for building a true safety culture happens *after* the emergency is over. The “hot wash,” or post-event debrief, is a structured meeting designed to analyze the response, identify failures, and create actionable plans for improvement. A poorly run debrief can quickly devolve into a blame session. A well-run, blame-free debrief is the engine that drives organizational learning.

Rules for a Blame-Free Debrief

When you participate in or lead a debrief, these principles are non-negotiable.

  • The Prime Directive: Start every debrief by stating this foundational assumption: “We believe that everyone involved did the best they could with the information and resources they had at the time.” The goal is to understand the system, not to judge individuals.
  • Focus on “What,” not “Who”: The questions should always be about the process. Instead of asking, “Bob, why did you forget to restock the cart?” ask, “What were the barriers that prevented the cart from being restocked in a timely manner?”
  • Structure the Conversation: Go through the event chronologically. Use a whiteboard to map the timeline and discuss three key questions: What was supposed to happen? What actually happened? What can we learn from the difference?
  • End with Action: The final output must be a list of concrete, assigned, and dated action items. “Jane will revise the code cart checklist by next Friday. Chris will add extra labels to the calcium chloride kits by the end of the month.”