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    1. Patient Safety Imperative to change attitude toward error. Everyone makes mistakes abandon defensiveness. IOM report call to arms , recognition that Medicine is a hazardous industry. Safe care is what its all about. Everyone here probably know how bad it feels when an error occurs (ex giving Ca# to Dig toxic patient could just be cognitive but maybe a drug ordering system which asked if patient on Dig before releasing the drug could have prevented it We have to change things! Its how we deal with error that defines us. And there is an enthusiasm to change Dont have to look far to see results aviation, nuclear power, anesthesia Physicians have a great opportunity to regain control Imperative to change attitude toward error. Everyone makes mistakes abandon defensiveness. IOM report call to arms , recognition that Medicine is a hazardous industry. Safe care is what its all about. Everyone here probably know how bad it feels when an error occurs (ex giving Ca# to Dig toxic patient could just be cognitive but maybe a drug ordering system which asked if patient on Dig before releasing the drug could have prevented it We have to change things! Its how we deal with error that defines us. And there is an enthusiasm to change Dont have to look far to see results aviation, nuclear power, anesthesia Physicians have a great opportunity to regain control

    2. Call to arms in 1999 Political document document as a result of results of Harvard medical practice study which showed nearly 4% of hospitalized patients suffered an adverse event and 30% were related to human error Most important outcome was to introduce fundamental concepts of safety in complex systems. This is common knowledge in most other high reliability organizations. Focus on process not individuals.Call to arms in 1999 Political document document as a result of results of Harvard medical practice study which showed nearly 4% of hospitalized patients suffered an adverse event and 30% were related to human error Most important outcome was to introduce fundamental concepts of safety in complex systems. This is common knowledge in most other high reliability organizations. Focus on process not individuals.

    3. Significance of Medical Error 44,000 - 98,000 deaths per year 3 jumbo jets crashing every other day 5th leading cause of death More in 6 months than in Vietnam Annual cost 37-50 billion dollars Magnitude is startling but, many have become too focused on number dont get caught up just realize it can be safer.Magnitude is startling but, many have become too focused on number dont get caught up just realize it can be safer.

    4. How Hazardous Is Health Care? Recognize Healthcare is hazardous We need to look at home to become a high reliability organization(learn and adapt from safe industry aviation, nuclear power Barriers to becoming safe Barach article Annals of Internal Medicine (C) 2005 American College of Physicians Volume 142(9), 3 May 2005, pp 756-764 Five System Barriers to Achieving Ultrasafe Health Care Although debate continues over estimates of the amount of preventable medical harm that occurs in health care, there seems to be a consensus that health care is not as safe and reliable as it might be. It is often assumed that copying and adapting the success stories of nonmedical industries, such as civil aviation and nuclear power, will make medicine as safe as these industries. However, the solution is not that simple. This article explains why a benchmarking approach to safety in high-risk industries is needed to help translate lessons so that they are usable and long lasting in health care. The most important difference among industries lies not so much in the pertinent safety toolkit, which is similar for most industries, but in an industry's willingness to abandon historical and cultural precedents and beliefs that are linked to performance and autonomy, in a constant drive toward a culture of safety. Five successive systemic barriers currently prevent health care from becoming an ultrasafe industrial system: 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, and the need for simplification. Finally, health care must overcome 3 unique problems: a wide range of risk among medical specialties, difficulty in defining medical error, and various structural constraints (such as public demand, teaching role, and chronic shortage of staff). Without such a framework to guide development, ongoing efforts to improve safety by adopting the safety strategies of other industries may yield reduced dividends. Rapid progress is possible only if the health care industry is willing to address these structural constraints needed to overcome the 5 barriers to ultrasafe performance.Recognize Healthcare is hazardous We need to look at home to become a high reliability organization(learn and adapt from safe industry aviation, nuclear power Barriers to becoming safe Barach article Annals of Internal Medicine (C) 2005 American College of Physicians Volume 142(9), 3 May 2005, pp 756-764 Five System Barriers to Achieving Ultrasafe Health Care Although debate continues over estimates of the amount of preventable medical harm that occurs in health care, there seems to be a consensus that health care is not as safe and reliable as it might be. It is often assumed that copying and adapting the success stories of nonmedical industries, such as civil aviation and nuclear power, will make medicine as safe as these industries. However, the solution is not that simple. This article explains why a benchmarking approach to safety in high-risk industries is needed to help translate lessons so that they are usable and long lasting in health care. The most important difference among industries lies not so much in the pertinent safety toolkit, which is similar for most industries, but in an industry's willingness to abandon historical and cultural precedents and beliefs that are linked to performance and autonomy, in a constant drive toward a culture of safety. Five successive systemic barriers currently prevent health care from becoming an ultrasafe industrial system: 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, and the need for simplification. Finally, health care must overcome 3 unique problems: a wide range of risk among medical specialties, difficulty in defining medical error, and various structural constraints (such as public demand, teaching role, and chronic shortage of staff). Without such a framework to guide development, ongoing efforts to improve safety by adopting the safety strategies of other industries may yield reduced dividends. Rapid progress is possible only if the health care industry is willing to address these structural constraints needed to overcome the 5 barriers to ultrasafe performance.

    5. Five Precepts for Error Management (Helmreich and Merritt, Culture at Work in Aviation and Medicine) Human Error is inevitable in complex systems Limitation of human performance imposed by cognitive capabilities High workload and stress increase error Safety is a universal value but there is a continuum. How much safety we want and what can can we afford? High Risk Organizations must develop a safety culture to make individuals and teams responsible Make physicians understand and accept these precepts and then they can move forward. While basic the culture of medicine trains us to believe we as individuals can overcome bad systems we should rather focus on how system should be designed to help provide safety barriers and plug holes in reasons swiss cheese modelMake physicians understand and accept these precepts and then they can move forward. While basic the culture of medicine trains us to believe we as individuals can overcome bad systems we should rather focus on how system should be designed to help provide safety barriers and plug holes in reasons swiss cheese model

    6. Error, stress and teamwork in medicine and aviation: cross sectional surveys crews (Sexton, BMJ,2000) Medicine more likely to deny the effects of stress and fatigue MD 60% v. CC 26% Staff did not acknowledge they make mistakes Surgeons more likely than intensivists and pilots to advocate hierarchies 45% v. 6% and 3% Good to talk about early because realizing are biases and addressing them will help us move forward. I know I was skeptical when we first got into teamwork and many still are that way. Culture of medicine will be slow to change and different specialties may be more or less amenable to nontechnical and cognitive interventions to improve safety.Good to talk about early because realizing are biases and addressing them will help us move forward. I know I was skeptical when we first got into teamwork and many still are that way. Culture of medicine will be slow to change and different specialties may be more or less amenable to nontechnical and cognitive interventions to improve safety.

    7. Clinician Attitudes About Teamwork Operating Room (Sexton JB et al. BMJ. 2000; 320(7237): 745-9) Only 55% of consultant surgeons rejected steep hierarchies Minority of Anesthesia and Nursing reported high levels of teamwork Critical Care (Thomas EJ et al. Crit Care Med. 2003; 31(3): 992-3) Discrepant attitudes between physician and nurses about teamwork 73% physicians High or Very High 33% nurses High or Very High Teamwork is essential to delivery of safe care. However in Medicine there is little formal training and aside from some routinely rostered teams such as cardiac surgery most teams are actually working groups with limited teamwork skills. Our goal is to make them high performing teams through teaching skills and behaviors such as those taught in aviation teamwork training.Teamwork is essential to delivery of safe care. However in Medicine there is little formal training and aside from some routinely rostered teams such as cardiac surgery most teams are actually working groups with limited teamwork skills. Our goal is to make them high performing teams through teaching skills and behaviors such as those taught in aviation teamwork training.

    8. 2001 AAMC Policy Statement 80 hour week maximum No more than 24 continuous hours ED and critical care only 12 hours 8 hours between duty shifts Maximum call 1 in 3 Day off every seven This is an example, while not aggressive enough finally recognized effect of fatigue on performance something long recognized in other high risk industries.This is an example, while not aggressive enough finally recognized effect of fatigue on performance something long recognized in other high risk industries.

    9. What is a Medical Error? An act or omission that would have been judged wrong by knowledgeable peers at the time it occurred Institute of Medicine Definition of error is difficult and may be difficult to come to consensus of definition but this is a guideline to use To improve safety and reduce medical error we need to accurately identify ,disclose and report errorsDefinition of error is difficult and may be difficult to come to consensus of definition but this is a guideline to use To improve safety and reduce medical error we need to accurately identify ,disclose and report errors

    10. Other Definitions Sentinel Event An unexpected incident involving death or serious physical or psychological injury, or risk thereof. Example: Incompatible blood given to a patient resulting in death. Incident Error makes it to the patient Does not require harm Near Miss / Close Call Used to describe any variation, which did not affect the outcome, but for which a recurrence carries a significant chance of a serious outcome. Example: Wrong medication is dispensed for a patient, but the error is identified before the patient received it.

    11. Schematic of definitions Not all adverse event are a medical error and many medical errors do not result in harm thankfully Schematic of definitions Not all adverse event are a medical error and many medical errors do not result in harm thankfully

    12. Human Error Models Person Traditional approach Unsafe acts, aberrant mental processes Counter-measures directed at human behavior System Approach Accepts fallibility Errors consequences, not causes System defenses Need to create shift away from traditional model of only focusing on contribution of individual in error. Person at sharp end Forgetful, unmotivated, negligent Does not work even though it may be more satisfying to blame someone System People make errors, difficult to change human condition Create defenses Safety is a balance of individual and system contributions both contribute to error occurrence and conversely error mitigation.Need to create shift away from traditional model of only focusing on contribution of individual in error. Person at sharp end Forgetful, unmotivated, negligent Does not work even though it may be more satisfying to blame someone System People make errors, difficult to change human condition Create defenses Safety is a balance of individual and system contributions both contribute to error occurrence and conversely error mitigation.

    13. This is a commonly used illustration to show how holes in the safety barriers when aligned can result in error. These holes are latent system weakness which should be the target of patient safety interventions. This could be process of medication administration and computerized entry could be an initiative to decrease the number of hole in a piece of cheese. Be aware new technology may close one hole and open others. Reason J: Managing the Risks of Organanizational Accicdents. Aldershot, UK, Ashgate Publishing Co, 1997.This is a commonly used illustration to show how holes in the safety barriers when aligned can result in error. These holes are latent system weakness which should be the target of patient safety interventions. This could be process of medication administration and computerized entry could be an initiative to decrease the number of hole in a piece of cheese. Be aware new technology may close one hole and open others. Reason J: Managing the Risks of Organanizational Accicdents. Aldershot, UK, Ashgate Publishing Co, 1997.

    14. System v. Person Balance between system and person Help clinicians to be part of HRO Address human factors training Integrate people and technology Dekker S. The Field Guide to Human Error Investigations. Ashgate Publishing, Limited. 2002, Burlington, VT. Shapiro MJ, and Jay GD. High Reliability Organizational Change for Hospitals: Translating Tenets for Medical Professionals. Qual Saf Health Care 2003; 12(4): 238-9. Safety is a balance of individual and system contributions both contribute to error occurrence and conversely error mitigation. While the pendulum has shifted to focusing on systems and sometimes too much on technology we need to also train our physicians to be an effective part of the system and be human factors system. The human contribution to safety should not be minimized. Safety is a balance of individual and system contributions both contribute to error occurrence and conversely error mitigation. While the pendulum has shifted to focusing on systems and sometimes too much on technology we need to also train our physicians to be an effective part of the system and be human factors system. The human contribution to safety should not be minimized.

    15. Finally, dont rely exclusively on new technology making patients safer..

    16. System Approach Advantages Effect a Cultural Change Enhances reporting Identifies recurrent patterns Promotes safeguards Even the best commit errors,not flawless under stress Effective risk management depends on reporting Latent system failure to improve process of care delivery.Even the best commit errors,not flawless under stress Effective risk management depends on reporting Latent system failure to improve process of care delivery.

    17. This is an expanded/ advanced schematic of Reasons error model, which illustrates the complexity of causes of medical error. It shows the impact of organizational decisions, work environment, resources and indivuduals. Most analysis of error only focuses on the active error (care management problem) and does not dig back to latent system problems or error producing conditions. This slide is busy but we want to give participant a deeper understanding of the complexity of how an incident occurs.This is an expanded/ advanced schematic of Reasons error model, which illustrates the complexity of causes of medical error. It shows the impact of organizational decisions, work environment, resources and indivuduals. Most analysis of error only focuses on the active error (care management problem) and does not dig back to latent system problems or error producing conditions. This slide is busy but we want to give participant a deeper understanding of the complexity of how an incident occurs.

    18. SYSTEM THINKING in other high risk industries Aviation - Zero deaths in 1998. Anesthesia - Deaths: 20 years ago 1 of 20,000 Today 1 of 200,000 Aluminum Refining (ALCOA) You cant make the safety better without having a profound understanding of the process. Use this to motivate participants the power of system v. individual in helping medicine transform its performance. Anaesthesia led the way by looking at technology and teamwork earlier than most medical specialties. Gaba DM, Howard SK, Fish KJ, Smith BE, Sowb YA. Simulation-based training in anesthesia crisis resource management (ACRM): A decade of experience. Simulation and Gaming. 2001;32(2):175-93.Use this to motivate participants the power of system v. individual in helping medicine transform its performance. Anaesthesia led the way by looking at technology and teamwork earlier than most medical specialties. Gaba DM, Howard SK, Fish KJ, Smith BE, Sowb YA. Simulation-based training in anesthesia crisis resource management (ACRM): A decade of experience. Simulation and Gaming. 2001;32(2):175-93.

    19. Error Management Lessons from High Reliability Organizations Airlines fatality rate 0.27 per 1,000,000 departures Serious medication errors 6.7 per 100 patients Human variability is desired Need to be preoccupied with failure Train for the eventual error Greater use of Simulation Nuclear power and aircraft carriers,aviation and maybe anesthesia Goals Managing complex tech and system to prevent catastrophe Capacity to meet high demand Nuclear power and aircraft carriers,aviation and maybe anesthesia Goals Managing complex tech and system to prevent catastrophe Capacity to meet high demand

    20. Your role? Seek non-technical safety education Error Models and Process Improvement Teamwork Decision Making Error Disclosure Identify and report incidents Participate in error disclosure Participate in local safety improvements and national goals (JCAHO)

    21. Mandates for Reporting JCAHO 2001 Standards Inform patients and, when appropriate, their families about the outcomes of care, including unanticipated outcomes