Kaiser Permanente: A Journey in In-Situ Medical Simulation . Stanford University, 2008 Paul Preston, MD Permanente Medical Group Regional Safety Educator. Thanks for the Invitation!. Without your leadership, we wouldn’t have a program You keep sending us great people who ask for this
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Kaiser Permanente: A Journey in In-Situ Medical Simulation
Stanford University, 2008
Paul Preston, MD
Permanente Medical Group
Regional Safety Educator
Largest non-profit HMO
8.3 million members
Headquarters Oakland, CA
431 medical offices
141,909 employees, 12,012 physicians
Modified from Reason, 1990
How many times have you done this before?
Do You have to manage emergencies?
Do your teams have to manage emergencies?
Do you practice as teams for these emergencies?
Do you routinely debrief your drills and your real events?
Would you learn from a near miss? Would your systems change?
If mistakes happen (and they will) we can trap them by working together as a Team
We can build systems that are safer
Everyone becomes the expert on Safety
We cannot become error free, but we can create a system that is harm free- and this will require testing of systems and training of providers
Ask for help when overloaded
Get a second opinion when in doubt.
Honor others who call for help
Wisdom, not weakness
It is more important for my patient to do well than for me to look slick
How do we do this better?
Proven Training Techniques: Human Factors
70% due to Human Factors (preventable?)
*MMI Company data of 250 hospitals over 10 years
Roll out dates by KP Region
“ I couldn’t believe how much we found on the first day, and how much better we look now”.
1 Airway Manager:
2 Airway Assistant: RT draw ABGs
6 Chest compressions
3 Bedside Nurse/Floor RN
briefs team, IV, labs, dispense items, CPR
7 Procedure MD
chest tubes, ABG’s, etc.
4 Critical Care RN
drugs, defib., ID
& monitor rhythm
8 Recorder RN
5 Team Leader
Optimum Location, people and equipment
Brief the Team
Know the environment, clearly delegate tasks
Clear Leader- (This may change!)
Regain Situational Awareness
Chaos is Never OK