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SUSP Sustainability Phase: Learning From Defects Through Sensemaking. Brad Winters, MD May 6 , 2014. Quick Administrative Announcements. You need to dial into the conference line: Dial in Number: 1-800-311-9401 Passcode: 8376 Webinar URL:

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Brad winters md may 6 2014

SUSP Sustainability Phase:

Learning From Defects Through Sensemaking

Brad Winters, MD

May 6, 2014

Quick Administrative Announcements

  • You need to dial into the conference line:

    • Dial in Number: 1-800-311-9401

    • Passcode: 8376

    • Webinar URL:

  • Please contact your Coordinating Entity for a copy of these slides if you have not already received them

  • We will make a recording of this webinar available.

  • We want you to interact with us today. You can:

    • Type comments in the chat box.

    • Or even better, speak up.

Polling question
Polling Question

  • What is your role in your clinical area?

    • Surgeon

    • Quality Improvement practitioner

    • Infection preventionist

    • OR nurse

    • OR technician

    • Anesthesiologist

    • OR manager

Learning Objectives

  • Describe difference between first-order and second-order problem solving

  • Use the Learning From Defects (LFD) tool to perform second-order problem solving

  • Explain how the LFD tool can be used to drive patient safety and quality improvement efforts

  • Use the four LFD questions to develop and sustain an improvement effort

Polling question1
Polling Question

  • Have you used the Learning from Defects tool?



Problem Solving Hierarchy


Problem Solving


Problem Solving

Recovers for one patient, but does not reduce risks for future patients.

Example: You get the supply from another area or you manage without it.

Reduces risks for future patients by improving work processes and increasing compliance.

Example: You create a process to make sure line cart is stocked with necessary equipment.

Activity: Share an example in the chat of common first-order problem solving in your work area.

What is the long term impact on patient safety culture

Problem Solving Goal

What is the long-term impact on patient safety culture?

What is a Defect?


you do not

want to happen


Individual mistake or system failing
Individual Mistake or System Failing?

Rather than being the main instigators of an accident, operators tend to be the inheritors of SYSTEM defects. . . . Their part is that of adding the final garnish to a lethal brew that has been long in the cooking.

-- James Reason, Human Error, 1990

Questions for Each Defect





Polling Question: Has your team learned from a defect?

Walk the process

What Happened?

Walk the process

  • Reconstruct the timeline and reenact what happened

  • Dig down to the reasoning and emotions behind actionsand decisions

  • Consider using visualization tools (ie. process mapping, diagrams, sketches or role playing) to break down complex defects and discover where steps go wrong

Tip: Take time to listen. Seek to understand rather than to judge. Ask clarifying questions and follow-up questions.

Critical to include adaptive teamwork concerns

Why Did It Happen?

Critical to include adaptive teamwork concerns

  • Develop a “system perspective” to see the hidden factors that led to the event

  • List all contributing factors and identify whether they harmed or protected the patient

  • Instrumental in building second-order problem solving skillsnecessary to learn from defects

Tip: Process mapping will uncover workflow issues, but it won’t get at values, attitudes, and beliefs impacting a defect. Thinking about the “people side” of a defect is critical to understanding how to create lasting change.

How Will You Reduce Risk of Happening Again?

  • Prioritize most important contributing factors and most beneficial interventions

  • Implement principles of safe design

  • Safe design principles apply to both technical tasks and adaptive team work

  • Tip: Take advantage of your diverse team!

  • Senior Executive’s big picture view of the organization and knowledge of resources

  • Team members’ connections throughout organization

  • Frontline staff with particular insight into the defect

Think low barrier high impact matrix

Prioritize Interventions

Think low barrier / high impact matrix

High Impact

Low Impact

Low Barrier

High Barrier

Pick a contributing factor to address first

How Will You Reduce Risk Reoccurring?

Pick a contributing factor to address first

Principles of Safe Design

Principles Of Safe Design

Standardize Care

Create Independent Checks

Learn From Defects

  • Patient safety is a property of systems.

  • Apply principles to both technical tasks and adaptive teamwork.

  • Teams make wise decisions when input is diverse, independent and encouraged.

Not all interventions are created equal

Building Resiliency into Intervention

Not all interventions are created equal.





Strive for concise clear and relevant messages

Not All Education Is Created Equal Either

Strive for Concise, Clear and Relevant Messages

  • Avoid information overload in all manners of disseminating information

  • Share a concise message with a clear focus relevant to specific audience needs

  • Experiential learning with hands-on approach will be far more effective at motivating change than an automated email dense with data

How Will You Know Risks Were Reduced?

  • Do staff know about the interventions?

  • Are staff using the interventions as intended?

  • Do staff believe risks were reduced?

  • Data driven metrics should be the goal whenever possible

Tip: Identify ways to measure success. Data is king, however subjective evaluations can provide valuable information. Ask your frontline staff about intervention compliance and effectiveness.

Share Success Stories

  • Summarize findings and changes over time

    • Hospital Patient Safety Culture Survey (HSOPS)

    • Safety Attitudes Questionnaire (SAQ)

  • Share - Provide updates on initiatives, goals and success stories to maintain engagement

  • Share de-identified analysis with others in collaborative (pending institutional approval)

Tip: Make staff safety assessments (refers to asking staff how the next patient will be harmed) available at all times. The team should review feedback on an ongoing basis.

Sustainability is dependent upon ongoing safety assessment exercises.


Patient safety culture requires constant vigilance

Ongoing Key Questions exercises.

Your Mantra!

Patient safety culture requires constant vigilance

Poll: Have you asked your frontline staff these questions? How often do you / they answer these questions?

Your team will likely be in many phases simultaneously

What’s Next? exercises.

Your team will likely be in many phases simultaneously.

Executive Exodus and Staff Turnover exercises.


Turnover Happens exercises.

  • Personnel turnover impacts all areas of organization

    • Frontline staff and clinicians

    • Executive officers

    • Team members

  • Invite new team members as defects evolve

  • Rotate existing team members as needed

  • CUSP teams need a depth of people with diverse experiences and exposures

Communicating for Patient Safety exercises.


Case Study: Renal Transplant exercises.

Opportunities For Improvement

System Failures

Knowledge, Skills & Competence

Anesthesiology attending not notified of the transfusion. Wrist band checks with stamp plate were not done at multiple points.

Create independent checks, encourage patient safety culture initiatives, add system constraints like barcoding technologies

Stagger staff changes

Formalize hand-offs between departments


Near simultaneous emergent events, change of two different provider groups at same time. No independent check.

Ensure hand-off process supports emergencies

Other Factors

Hospital environment: Transfer across units

Patient characteristics: High acuity

Task characteristics: Blood check-in only as good as existing identity documents.

Key Takeaways exercises.

  • Focus on systems, not people

  • Prioritize

  • Use Safe design principles

  • Go mile deep and inch wide rather than mile wide and inch deep

  • Pilot test

  • Learn from defects on a regular basis

  • Answer the 4 questions

Action Plan exercises.

  • Review the Learning from Defects tool with your team

  • Review a defect in your operating rooms

  • Select one defect per month

  • Consider using in surgical morbidity and mortality conferences

  • Post the stories of reduced risks (with data!!)

  • Share with others

References exercises.

Bagian JP, Lee C, et al. Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. Jt Comm J QualImprov 2001;27:522-32.

Pronovost PJ, Holzmueller CG, et al. A practical tool to learn from defects in patient care. JtComm J Qual Patient Saf 2006;32(2):102-108.

Pronovost PJ, Wu Aw, et al. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Int Med 2004;140(12):1025-1033.

Reason J. Human Error. Cambridge, England: Cambridge University Press, 2000.

Wu AW, Lipshutz AKM, et al. The effectiveness and efficiency of root cause analysis. JAMA 2008;299:685-87.