Lecture MDR VU
•
1 recomendación•626 vistas
Lecture for VU on patient safety in the OR and the Medical Data Recorder
Recomendados
Recomendados
Más contenido relacionado
Similar a Lecture MDR VU
Similar a Lecture MDR VU (20)
Más de Martijn Kriens
Más de Martijn Kriens (20)
Último
Último (20)
Lecture MDR VU
- 1. Safety in the OR Martijn Kriens @martijnkriens, martijn.kriens@icrowds.net The old operating theatre, London
- 2. Martijn Kriens Medical Data Recorder Research Quality Assurance Pilot @martijnkriens, martijn.kriens@icrowds.net
- 3. Human Fallibility Systemic learning Medical Data Recorder Entrepreneurship in healthcare
- 4. Human Fallibility Truth emerges more readily from error than from confusion Francis Bacon
- 6. TO BE HUMAN IS TO ERR
- 10. We nemen het anderen meer kwalijk dat ze onze fouten kennen, dan onszelf dat wij daaraan mank gaan. Multatuli We hold it more against others to know our failures, than to hold our failures against ourselves Multatuli (Dutch writer)
- 12. 10-2 10-3 10-4 10-5 10-6 10-7 Himalaya mountaineering (3x10-2) Aviation (6x10-7) Hospital (6x10-4) Amalberti
- 13. 1,6% 970 126M
- 14. 1. (Vrijwel) geen aanwijzingen 2. Geringe aanwijzingen 3. minder dan 50-50 maar ‘close call’ 4. meer dan 50-50 maar ‘close call’ 5. Sterke aanwijzingen 6. (Vrijwel) zeker aanwijzingen Vermijdbaarheid van schade
- 15. 0,0% 0,4% 0,8% 1,2% 1,6% Diagnose Surgical Treatment Medication Care Release Others 2004 2008 2012 Surgery is responsible for 60% of all Avoidable Errors (22.500) Monitor Zorggerelateerde Schade 2012, NIVEL Direct costs are > 126M euro per year
- 18. Systemic learning I am always ready to learn although I do not always like to be taught Winston Churchill
- 20. Small errors, serious consequences Split second decisions Individual skills and teamwork
- 21. I know a lot of doctors who became recreational pilots, but I don’t know one pilot who became a recreational doctor. http://skepticalscalpel.blogspot.nl/2011/01/surgeons-are-not-pilots.html
- 27. KLM (RADIO) Ah roger, sir, we are cleared to the Papa Beacon flight level nine zero until intercepting the three two five. We are now at take-off … TENERIFE TOWER OK....[static noise] ... (KLM initiates take-off) TENERIFE TOWER Ah, papa alpha one seven three six report the runway clear. PAN AM (RADIO) OK, will report when we're clear. ... KLM FLT ENGR (CVR) [Is he not clear, that Pan American?] KLM CAPTAIN (CVR) [Oh yes. - emphatic] [Pan Am captain sees landing lights of KLM Boeing at approx. 700 m] PAN AM CAPTAIN There he is ... look at him. Goddamn that son-of-a-bitch is coming! http://planecrashinfo.com/cvr770327.htm
- 28. KLM (RADIO) Ah roger, sir, we are cleared to the Papa Beacon flight level nine zero until intercepting the three two five. We are now at take-off … TENERIFE TOWER OK....Stand by for take-off, I will call you. ... (KLM initiates take-off) TENERIFE TOWER Ah, papa alpha one seven three six report the runway clear. PAN AM (RADIO) OK, will report when we're clear. ... KLM FLT ENGR (CVR) [Is he not clear, that Pan American?] KLM CAPTAIN (CVR) [Oh yes. - emphatic] [Pan Am captain sees landing lights of KLM Boeing at approx. 700 m] PAN AM CAPTAIN There he is ... look at him. Goddamn that son-of-a-bitch is coming!
- 29. PLANE1234: [call sign] ready for departure at Runway three zero TOWER: [call sign], you are cleared for take off Runway three zero PLANE5678: [call sign] Runway vacated Lessons Tenerife
- 31. Education Improvement begins with I Arnold Glasow
- 33. Not Received 7%Not Transmitted 49% Misunderstanding 44% Patterns of Communication Breakdowns Resulting in Injury to Surgical Patients, Greenberg, 2007 Failures due to communication errors (60 out of 258)
- 34. Blood pressure is 60! Fuck off and concentrate on your own job
- 35. (my) Observations • High fault tolerance • Strong hierarchy • Going through the motions of checklists • Chasm between disciplines • Unreliable documentation http://www.icrowds.net/2014/01/observatie-in-de-operatiekamer/
- 36. Plan Do Check Act Crew Resource Management (CRM) Medical Data Recorder (MDR) Assurance in processes Improvement of processes Plan the proces - checklists, … Do according to agreed processes Check expected outcomes with reality Act on deviations - analise and adapt
- 38. Central line checklist 1. Wash your hands with soap. 1. Clean the patient’s skin with chlorhexidine antiseptic. 2. Put sterile drapes over the entire patient. 3. Wear a sterile mask, hat, gown and gloves. 4. Put a sterile dressing over the catheter site. Berenholtz, S. M., Pronovost, P. J., Lipsett, P. a., Hobson, D., Earsing, K., Farley, J. E., … Perl, T. M. (2004). Eliminating catheter-related bloodstream infections in the intensive care unit*. Critical Care Medicine, 32(10), 2014–2020
- 40. Stop and count to 10 Think about your options Do what you think is best V V V Checklists
- 41. Pause points • Preparation • Team start • Incision • Reach target • Treatment • Repairing • Closing • Hand-over • Risks / abnormalities • Pre-conditions • Postconditions • Checks • Activities }{
- 42. Is your name Pietje Puk? Is urine produced? Does your left kidney needs to be removed? Multiple questions, one answer …. Questions
- 45. Retirement age Surgical instruments Open communication Hierarchies … Examples of barriers
- 46. Safety culture 45% of surgeons think junior team members should not question decisions compared to 6% of pilots 70% of surgeons say they have no averse effect of fatigue compared to 26% of pilots 62% of surgeons rate teamwork with anaesthetists high compared to 42% of anaesthetists with surgeons Error, stress, and teamwork in medicine and aviation: cross sectional surveys J Bryan Sexton, Eric J Thomas, Robert L Helmreich, 2000
- 47. Reporting errors 50% find it difficult to report errors reasons of underreporting personal reputation (75%) Claims (71%) Expectations of surroundings (68%) Error, stress, and teamwork in medicine and aviation: cross sectional surveys J Bryan Sexton, Eric J Thomas, Robert L Helmreich, 2000
- 48. 1. Compensate quickly and fairly when unreasonable medical care causes injury. 2. Defend medically reasonable care vigorously 3. Reduce patient injuries (and therefore claims) by learning from patients’ experiences. Boothman, R., & Blackwell, A. (2009). A better approach to medical malpractice claims? The University of Michigan experience. Journal of health & life sciences law, 2(2) • 50% less judicial costs • From 20 to 8 months University of Michigan claims
- 49. Safety culture • Reporting culture • Just culture • Flexible culture • Learning culture Informed culture } James Reason: Managing the risks of organizational accidents
- 50. Reporting culture • Indemnity for honest mistakes • Confidentiality • Separation of analysis and authority • Timely and relevant feedback • Ease of reporting Trust
- 53. Just culture • Intentions - actions - consequences • Negligence, criminal intent • Honest mistakes • Learning over prosecution Balance
- 56. Flexible culture • Strict organisation of default processes • Ability to switch from top down to bottom up • Risk aware Shared stories
- 57. Fewer planes crash when the co-pilot is flying…
- 59. Learning culture • Observing, reflecting, creating, acting • Priority on proces Implementation
- 62. Unsafe acts Workplace Organization Active failures and Latent conditions
- 63. Unsafe acts Workplace Organization Active failures and Latent conditions
- 64. Non-Technical skills • Situational awareness • Gathering information, Understanding information, Projecting and anticipating future state • Decision making • Considering options, Selecting and communicating options, Implementing and reviewing decisions • Communication and teamwork • Exchanging information, Establishing a shared understanding, Coordinating team activities • Leadership • Setting and maintaining standards, Supporting others, Coping with pressure NOTSS handbook 1.2, 2006
- 65. AnticipationContaiment • Preoccupation with failure • Actively find failures and learn • Reluctance to simplify – Challenge beliefs, don’t stop asking why • Sensitivity to operations • Grasp context and flow • Commitment to resilience • Discipline, know what is important • Deference to expertise – Open channels http://www.beckershospitalreview.com/hospital-management-administration/5-traits-of-high-reliability-organizations-how-to- hardwire-each-in-your-organization.html?goback=%2Egde_4877284_member_240196966 High reliability organisations Failure Succes ? ? ?
- 66. Errors are seen as consequences instead as causes
- 67. • Collective memory • Shared stories • Evidence based processes • organizational quality • Team focus • Hierarchy • An error does not imply guilt © Medical Data Recorder Lessonsforsurgery
- 68. Things that never happened before happen all the time Scott D. Sagan The limits of safety
- 71. Medical Data Recorder Facts do not cease to exist because they are ignored. Aldous Huxley
- 74. There is no evidence to suggest …
- 77. MeDaRec
- 78. Entreneurship Success is stumbling from failure to failure with no loss of enthusiasm.” Winston Churchill
- 80. 2009: start ReMarketable 2010: idea for OR black box 2010: 1st Contact RadboudUMC 2013: Trial in animal OR 2014: Agreement Justice department & Inspection 2015: first 10 takes in RadboudUMC 2016: Start UMCG?
- 82. Safety Culture
- 83. External forces • Production pressures • Visibility of accidents for the general public • Can it happen to everyone or only a small group • Can we depend on our skills
- 84. % Safety thinking Evidence based Safety culture
- 86. Defences • Understanding and awareness • Guidance • Alarms and warnings • Restore • Containment • Escape and rescue
- 87. Barriers • the need to limit the discretion of workers • the need to reduce worker autonomy • the need to make the transition from a craftsmanship mindset to that of equivalent actors • the need for system-level (senior leadership) arbitration to optimize safety strategies • the need for simplification Editors, S., Barach, P., Amalberti, R., Auroy, Y., & Berwick, D. (2005). Improving Patient Care Five System Barriers to Achieving Ultrasafe Health Care.
- 88. Risks Known un-knowns (meta instructions (think!)) “If .. stop and think” Known knowns (training, checklists, ..) “Do this” Un-known knowns (implicit culture) “This is how we do it” Un-known un-knowns (resilience) “Do not take anything for granted” Do we know the risk? Do we know how to deal with the risk?
- 89. Dimensions • type of expected performance • from daily routine work to highly innovative, and standardized or repetitive • interface of health care providers with patients • from full autonomy to full supervision • type of regulations • from few recommendations to full specification of regulations at an international level • pressure for justice after an accident • from little judicial scrutiny to routine lawsuits against people and systems • supervision and transparency by media and people in the street of the activity • from little concern to high demand for national supervision Editors, S., Barach, P., Amalberti, R., Auroy, Y., & Berwick, D. (2005). Improving Patient Care Five System Barriers to Achieving Ultrasafe Health Care.
- 90. “A lot of you are going to have to make decisions above your level. Make the best decision that you can with the information that’s available to you at the time, and, above all, do the right thing” Lee Scott, CEO Walmart (day before Katrina)
- 91. Non-technical skills Non-technical skills are decision making and interpersonal skills needed to work together as a team
- 93. 93
- 94. 94
- 96. • To be human is to err … • “Safe” incident reporting • Systemic errors • Learning, not prosecution • Gross negligence remains punishable – Honest mistakes not punitive blame free safety
- 97. Two orders of magnitude (100x)
- 98. 1 incident = 10 “almost”- incidents (plenty of oppurtunity to learn)
- 99. Communication
- 100. Hurdles of communication Meant Said Heard Understood Said Heard Understood Done ≠ ≠ ≠ ≠ Rall M, Gaba D. Human performance and patient safety. In: Miller R, editor. Miller's Anesthesia. Philadelphia: Elsevier Churchill Living- stone; 2005. p. 3021-72.
- 101. “operate by voice” “Perhaps we need to intubate” “what are we missing” Meant is not said
- 102. Said is not heard Mumbling “….” “I think I am going to”
- 103. Heard is not understood “Stop and Listen” “My Patient”, “Your Patient” Read-back Missing meaning due to multi-tasking “Maybe I should”
- 104. Understood is not done “Report when done” “do this”
- 105. Situation “Blood pressure is below 60” Background “Life signs are critical” Assessment “Extensive blood loss will lead to a dangerous situation” Recommendation “Do not proceed”
- 106. Citing names Sandra Clear instructions Check for bleeding on the left Closed loop Report when finished
- 108. • Team Leadership • Backup Behavior • Mutual performance monitoring • Communication adaptability • Shared mental models • Mutual trust • Team orientation Baker, D. P., Day, R., & Salas, E. (2006). Teamwork as an essential component of high-reliability organizations. Health services research, 41(4 Pt 2), 1576–98
- 109. • hypercomplexity • tightly coupled • extreme hierarchical (role) differentiation • many decision makers working in complex communication networks • high degree of accountability • frequent, im- mediate feedback regarding decisions • compressed time factors • synchronized outcomes Charactaristics HRO’s
- 110. Adverse events
- 111. 3,7% adverse events (3,2 to 4,2) 27,6% of adverse events are preventable (22,5 to 32,6) 70,5% > 6 month, 2,6% permanent, 13,6% death Harvard Medical Practice Study, 1991 (records from 1984)
- 112. Safety culture Act lessons learned adaption to instruments analyses of outcomes analysis of processes Check observation Do Plan checklists training syllabi formal communication
- 113. Plan the proces - checklists, … Do accoording to agreed processes Check expected outcomes with reality Act on deviations - analise and adapt
- 116. Cabana, M., Rand, C., & Powe, N. (1999). Why Don’t Physicians Follow Clinical Practice Guidelines?
- 117. Gut feeling Task management Teamwork Leadership 1. The team leader let the team know what was expected of them through direction and comma 2. The team leader maintained a global prospect 3. The team communicated effectively 4. The team worked together to complete tasks in a timely manner 5. The team acted with composure and control 6. The team morale was positive 7. The team adapted to changing situations 8. The team monitored and reassessed the situation 9. The team anticipated potential actions 10.The team prioritized tasks 11.The team followed approved standards/guidelines Total 12.global rating Cooper, S., Cant, R., Porter, J., Sellick, K., Somers, G., Kinsman, L., & Nestel, D. (2010). Rating medical emergency teamwork performance: development of the Team Emergency Assessment Measure (TEAM). Resuscitation, 81(4), 446–52.
- 118. we do well we could do more of we could do less of One thing