The Human Factor : Teamwork and Communication in Patient Safety

1. The Human Factor : Teamwork and Communication in Patient Safety Michael Leonard, MD April 14, 2004 Dearborn, Michigan

2. Our Conversation • Why communication is the heart of the matter • The limits of human performance • Lessons from high reliability • Human Factors Skills: Briefings– Time Outs, Pauses; Assertion – It’s a hierarchical world; Situational Awareness; Debriefing

3. A System Error

4. Drawing the Bright Line Malicious Substance Use Violation of Rules Repeat Events Competency = remediate NO RULE = Substitution Test Safe Harbor – Systems Approach Reason, J.

5. Why Communication ? • The overwhelming majority of untoward events involve communication failure • Somebody knows there’s a problem but can’t get everyone in the same movie • The clinical environment has evolved beyond the limitations of individual human performance

6. Reoccurring Organizational Systems Problems • Communication • Shift reports, sign outs and hand-offs • Inadequate, inaccurate information • Task fixation, task overload • Assertion, escalation of communication • Supervision, leadership * MMI Company data of 250 hospitals over 10 years

7. Our Error Model Today • Trained to be perfect - knowledge and competence are equated with the absence of error. • Medical culture rewards perfection and frowns upon error. • Individual agency - fix the person and the problem goes away.

8. Error is Inevitable Because of Human Limitations • Limited memory capacity – 5 pieces of information in short term memory • Negative effects of stress – error rates • Tunnel vision • Negative influence of fatigue and other physiological factors • Limited ability to multitask – cell phones and driving • Flawed judgment

9. Anesthesia Error • Human error accounts for 80% • Failure to perform normal check • Lack of proficiency with equipment • Lack of vigilance, distraction • Haste • Lack of experience with technique Cooper et al, Anesthesiology, 1984

10. JCAHO Sentinel Events • Communication breakdowns remain the primary root cause of more than 60% of the 2034 sentinel events analyzed. • The majority of sentinel events (75%) resulted in a patient death. • Suicide (16.1%) • Operative/postop complications (12.4%) • Wrong-site surgery (11.8%) • Medication errors (11.5%)

11. JCAHO Patient Safety Goals • Read-backs on verbal orders • Identify patient from 2 sources • Verification of correct patient, correct site, correct procedure • Briefings before procedures, operations • Infusion pumps / monitor alarms • Nosocomial Infections

12. What Does America Think ? • 42% of Americans have had personal experience with a medical error • In 38% of those cases, the system was unresponsive

13. What Do Patients Want After a Medical Error ? • An honest explanation. • An apology. • A guarantee it won’t happen to anyone else. • Lexington VA experience.

14. MD –RN: Different Communication Styles • Nurses are trained to be narrative and descriptive • Physicians are trained to be problem solvers “ what do you want me to do” – “ just give me the headlines” • Complicating factors: gender, national culture, the pecking order, prior relationship • Perceptions of teamwork depend on your point of view

15. ICU Teamwork: Discrepant RatingsAveraged across 32 ICUs – Dr. Bryan Sexton

16. Quality of Teamwork across 25 organizations:Differences between Physicians & Nurses Quality of Teamwork Scale (1=very low to 5=very high)

17. Low Turnover 7.9% Mid Turnover 10.8% High Turnover 16.0% Teamwork Climate &Annual Nurse Turnover % reporting positive teamwork climate

18. SYSTEMS OF CARE • 80 % medical error is system derived • 95% mistakes – the good guys • Get the bad apples – no ! • Fix – hard to do the wrong thing, predictability

19. United Portland – Human Factors Surface

20. Crew Resource Management • Focus on teamwork,communication, flattening hierarchy, managing error, situational awareness, decision making • Non-punitive reporting of near misses, 500,00 reports over 15 years • Very open culture with regard to error and safety

21. High Reliability • Preoccupation with Failure • Refusal to Simplify • Commitment to Resilience • Deference to Expertise • Sensitivity to Operations

22. High Reliability Units* • Safety first is the hallmark of the culture • Team contribution is valued • Communication is structured and rewarded • MD comes when called by RN • L&D is viewed as “potentially dangerous” to guard against complacency • Fetal and maternal wellness are defined • Evidence-based protocols are utilized • Emergencies are rehearsed * Knox, Simpson, JHRM, Spring 99

23. What Lessons Can We Learn From Industry ?

24. Industry LeadersOperationally excellentConsistently profitableExcellent workforce morale • Toyota • Southwest Airlines • Alcoa

25. 3 Conditions of Habitual Excellence • A fundamental, non-negotiable respect for every employee every day by everyone they meet • The tools and flexibility to do the job • The work is recognized and acknowledged Paul O’Neill – NPSF 2003

26. Is Technology the Answer ?

27. HUMAN FACTORS • Briefings • Appropriate Assertion • Situational Awareness • Debriefing • Common Mental model

28. Setting the Stage • Vascular surgeon doing new, complicated procedure – endovascular aortic stent - in CV lab: “ I don’t have any pride invested here. I just want to get this right, so if you think of anything helpful or see me doing anything wrong, please let me know.”

29. “I know the names of all the personnel that I worked with during my last shift” % of respondents who agreed

30. Briefings - Key Elements Checksheet • Got the person’s attention • Made eye contact, faced the person • Introduced self • Used person’s name – familiarity is key ! • Asked knowable information • Explicitly asked for input • Provided information • Talked about next steps • Encouraged ongoing monitoring and cross-checking

31. Situational Briefing Model S-B-A-R • Situation • Background • Assessment • Recommendation

32. Situational Brief Example • Situation: Dr. Jones, I’m Paul, the respiratory therapist. In my HF training, I was told to get help if I am worried about a patient. There’s someone downstairs who’s in serious respiratory distress. • Background: He has severe COPD, has been going downhill, and is now acutely worse..

33. Assessment: His breath sounds are way down on the right side … I think he has a pneumothorax and needs a chest tube pronto before he stops breathing. • Recommendation: I’d like you to come with me now and see him…I really need your help…this guy’s in real trouble.

34. Assertion - What is it? “Individuals speak up, and state their information with appropriate persistence until there is a clear resolution.”

35. * Assertion • Model to guide andimprove assertion inthe interest of patient safety

36. Why is Assertion So Hard ? • Hierarchy / power distance • Lack of common mental model • Don’t want to look stupid • Not sure I’m right • Other?

37. Situational Awareness – Recognizing Adverse Events

38. Expert Decision Making • Expert – pattern matching against large mental library, quick, accurate if confirm correct answer • Novice – library is empty – slow, error prone process • Certain Diagnoses are Favored- Frequent, Recent, Serious • Heuristics

39. Red Flags – Loss of Situational Awareness • Ambiguity • Reduced/poor communication • Confusion • Trying something new under pressure • Deviating from established norms • Verbal violence • Doesn’t feel right • Fixation • Boredom • Task saturation • Being rushed / behind schedule

40. Debriefing • An opportunity for individual, team and organizational learning • The more specific, the better • What did we do well? • What did we learn? • What would we do differently next time ? • Key element in HBR study – Bohmer, Edmondson and Pisano

41. The quality of the debrief is closely linked to the quality of the initial briefing