The High Reliability Emergency Department

1. The High Reliability Emergency Department Grand Rounds December 7, 2011, SJRMC David J. Adinaro MD, MAEd, FACEP Chief, Adult Emergency Department, EM Residency Research Director

2. Disclosures • I have nothing to report in terms of financial disclosures.

3. Biases • That I have the best job in the world • That I work with the best people in the best profession • That we do noble work • That we can do better I believe

4. Objectives • Understand the concept of HROs • Identify the similarities between EDs and other HROs • Identify ways to be more mindful in our everyday care of patients

5. Definitions • High Reliability Organizations

6. HRO • A High Reliability Organization (HRO) is an organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity

7. Definitions • A NORMAL ACCIDENT or SYSTEM ACCIDENT is an “unanticipated interaction of multiple failures in a complex system”. • Requires both INTERACTIVE COMPLEXITY and TIGHT COUPLING to be present in the system.

8. Reason’s Model of Normal Accidents

9. Example of Normal Accident • Trauma patient suddenly becomes unresponsive and apneic shortly after extubation s\p diagnostic work up in the Emergency Department of a Level I trauma center. • Requires emergent reintubation for a short period of time.

10. Example of Normal Accident • Hospital policy of properly labeling unmarked meds not routinely followed. • Standardized labeling not available. • Teams performing intubations do not routinely ensure\witness proper disposal of dangerous medications.

11. Example of Normal Accident • In order to flush Hep Lock nurse uses apparently unused normal saline in 10cc syringe left at bedside • Prepackaged flushes not routinely available so NS generally drawn into similar 10cc syringes.

12. Example of Normal Accident • RESULTS: Patient is unintentionally injected with 60-80mg of Succinylcholine.

13. Example of Normal Accident • Take a moment to write down an example of a NORMAL ACCIDENT you witnessed, participated in, and\or prevented recently.

14. Reason’s Model of Normal Accidents

15. Environment of an HRO • Hypercomplexity- HROs exist in complex environments that depend on multi-team systems that must coordinate for safety • Tight coupling - HROs consist of tightly coupled teams in which the members depend on tasks performed across their team • Extreme hierarchical differentiation - In HROs, roles are clearly differentiated and defined. Intensive coordination efforts are needed to keep members of the teams working cohesively • Multiple decision makers in a complex communication network - HROs consist of many decision makers working to make important, interconnected decisions • High degree of accountability - HROs have a high degree of accountability when an error occurs that has severe consequences • Need for frequent, immediate feedback - HROs exist in industries where team members must receive frequent feedback at all times • Compressed time constraints - Time constraints are common to many industries, including health care

16. HRO Principles 4) Commitment to resilience 5) Deference to expertise • 1) Preoccupation with failure • 2) Reluctance to simplify • 3) Sensitivity to operations

17. HRO • Aircraft carrier flight operations • Nuclear Power Plants • Fireground Operations (especially wildfire) • Emergency Departments!

18. HRO Principle #1 • Preoccupation with failure • Encourage reporting of errors • Treating any lapse as a symptom that something may be wrong with the system. • Using near-misses for what can be learned. • Accepting that small failures can have an additive effect and lead to Natural Accidents. • Continually articulating mistakes they don’t want to make.

20. HRO Principle #1 • Preoccupation with failure • Naval Flight Operations • Obsessed with finding failure. • Every landing is televised, reviewed, graded, and grades used to improve performance. • Everyone sees how everyone else performs. • Near Misses • Debriefed within the hour. • Everyone documents what they saw and\or heard prior to incident. • Treated as signs of potential larger problems.

21. Crashes spur Navy to ground all its aircraft for safety review ACROSS THE NATION March 05, 2006|By Items compiled from Tribune news services. WASHINGTON, D.C. — Plagued by a series of helicopter and jet crashes in recent months, the Navy has decided to ground all its aircraft for half a day this week for an internal safety review. The stand-down will affect 3,800 aircraft and thousands of naval aviation personnel, including aircraft on 12 carriers around the world. It is the first time since 1997 that such a pause in flight operations across the Navy has been ordered. Since Oct 1. there have been major crashes that resulted in loss of life or of the aircaft. Nine aircraft were destroyed and 10 aviators killed.

22. HRO Principle #1 • Preoccupation with failure • Examples of Violations • Bent Spear – USAF Nuclear Weapons Incident • Warheads left without special protections for 36 hours after mistakenly being loaded on B52 • Investigations show multiple near misses prior. • Resignations starting with Secretary of Air Force. • Changes to handling procedures\training.

24. HRO Principle #1 • Preoccupation with failure • Examples of Violations • Cerro Grande Fire • Planned “Prescribed Fire” of 300 acres near Santa Fe, NM. to reduce risk of wildfires. • Crew of 20 Firefighters ignite a 3 foot perimeter before planning to burn interior. • Failures noted to contain perimeter fires prior to burn of interior. • 15 days later fire finally under control after being fought by 1,000 firefighters burning 48,000 acres and causing $1 billion in damage.

25. HRO Principle #1 • Preoccupation with failure • Emergency Department • Incident Reporting • EDQA Process • 400 charts and still going • Large focus on systems issues • Need to change disincentives for reporting errors. • Need to recognize near-misses as small failures.

26. HRO Principle #2 • Reluctance to Simplify • Less Simplification = Broader awareness. • A view that the world is complex, unstable, unknowable, and unpredictable. • Welcomes diverse experience, skepticism toward received wisdom. • Understands that superficial similarities between the present and the past mask deeper differences that could prove fatal. • Mindfulness – to have a rich awareness of discriminatory detail and enhance ability to discover and correct errors that could escalate into a crisis.

28. HRO Principle #2 • Reluctance to Simplify • NASA (Columbia Space Shuttle Accident) • Tendency to simply problems. • Distinction between “in-family” and “out-of-family” problems. • “In-family” label used for problems already analyzed and understood. • Burn marks to O-Rings noted on earlier flights. • After analysis this was determined to be an “in-family” problem.

29. HRO Principle #2 • Reluctance to Simplify • NASA (Columbia Space Shuttle Accident) • Continued concerns about O-Rings ignored as they were already determined “in-family”. • Multiple waivers granted related to O-rings. • January 28, 1986 Challenger broke apart 73 seconds into launch. • All seven astronauts including civilian teacher killed.

30. HRO Principle #2 • Reluctance to Simplify • Emergency Department • Commitment to mindfulness. • Is that patient supposed to look that way???? • Overcoming reluctance to express concerns. • Responding immediately to others’ concerns. • Actively searching for disconfirming data.

31. HRO Principle #2 • Reluctance to Simplify • Emergency Department • Simplification a major source of diagnostic medical error. • Frequently physicians cut off exploration of patient’s condition too early. • Use of pattern recognition a double-edged sword. • Often results in “closest fit” approach. • Results in missed diagnoses and delayed care. • Classic example is overdiagnosis of gastroenteritis in other serious conditions (appendicitis, etc.) • Healthy skepticism and accounting for all findings help prevent these errors.

33. HRO Principle #3 • Sensitivity to Operations • Attentive to the front line. • = Sensitivity to Relationships. • Ensures resources needed to accomplish mission are available. • Works hard to break down silos. • Encourages communication within and between departments. • Attempts to keep focus on the “Big Picture” . • Processes a “near miss” not as success (I caught the patient before she strangled herself) but as a small failure ((failure to identify and respond to suicide risk). • Looks for “small wins” in improving system.

34. HRO Principle #3 • Sensitivity to Operations • Wildland Firefighting • Standard analysis of all fires to find errors and ways to improve. • Adherence to 10 Standard Fire Orders • Keep informed of conditions. • Know what your fire is doing at all times. • Identify escape routes and safety zones. • Be alert. Keep calm. Think clearly. Act decisively. • Give clear instructions and insure understanding. 10) Fight fire aggressively, having provided safety first.

36. HRO Principle #3 • Sensitivity to Operations • Storm King Tragedy (South Canyon Fire 1994) • 14 highly experienced firefighters lose their lives when the fire jumps the line they were digging trapping them on a ridge. • Overly aggressive tactics combined with lack of support and no planned escape route. • Warning of high winds not communicated. • Later determined leadership at fire scene also lacking.

37. ED Operations PICTURE

38. HRO Principle #3 • Sensitivity to Operations • Emergency Department • Communication, communication, communication. • Communicate up, down and around. • Never assume other possess what you know. • Report near-misses. Treat them seriously. • Look for the “small wins”.

39. HRO Principle #3 Sensitivity to Operations • Emergency Department – small wins • Small Wins – produce change without confronting the system directly or aggressively. • Recent examples: • Use of Admin sign to denote pending bed assignment. • Pneumonia ABX guide. • Physician Reference guide. • Impact is from examples they provide others. • Through doing something tangible. • Through showing change is possible.

40. HRO Principle #3 • Sensitivity to Operations • Emergency Department – small wins • Write down an issue ripe for a small win.

41. HRO Principle #4 • Commitment to Resilience • Intrinsic ability of a system to maintain or regain a dynamically stable state, allowing continued operations after a major mishap or in presence of continuous stress. • Involves recognition that no system is perfect. • Combination of keeping errors small and of improvising workarounds to keep system functioning.

42. HRO Principle #4 • Commitment to Resilience • Emergency Department. • We own this hands down. • We operate in a near continual state of stress that requires significant resilience. • Our motto: Anyone, Anything, Anytime. • ‘Nuff said.

43. HRO Principle #5 • Deference to Expertise • Pushes decision making down and around. • Decisions are made on the front line. • Authority migrates to the people with the most expertise. • Makes an effort to see what people with greasy hands know. • Does not mistake expertise with experts.

44. HRO Principle #5 • Deference to Expertise • Emergency Department • At times goes against the hierarchal nature of medicine. • Does fit in well with the golden rule (when in doubt….consult). • Dependent on the free flow of information and respect for colleagues. • Made easier when focus is on “Big Picture”. • Not a sign of weakness.

45. SJRMC ED Operations • Embraces many aspects of HRO. • Expectation of continued improvement and need for change is most important asset. • Improving communication is crucially important. • Feedback from the sharp end is vital. • Adinarod@sjhmc.org • Office: 973-754-3735.

46. Thank You!