Learning From Our Mistakes

1. 2nd Annual Ellison Pierce Symposium Positioning Your ORs For The Future Learning From Our Mistakes Susan Haas, MD, MSc Senior Vice President & Chief Medical Officer Boston Medical Center Boston University School of Medicine May 18, 2006 10:30-11:00am

2. Do you feel your organization is capable of preventing recurrence once a problem occurs? QUESTION: • Yes • No 0 / 10

3. Have any of the following occurred in your practice in the last 5 years (most recent)? QUESTION: • Wrong site surgery • Serious drug error • OR fire • Case with retained foreign body • Uncomfortable with the question and answering 0 / 10

4. “OK…listen, please do not break the window…because there’s so much smoke outside…you guys won’t be able to breathe. O.K.? O.K.?” 911 operator: Sept 11, 2001

5. Error Recognition Understanding Improvement Overview

6. Errors: Overview • Types • Systemic Nature

7. Error: Types • Communication • Procedural • Proficiency • Decision • Violation of formal policy/procedure

8. Error: Examples of Types • Wrong treatment for that illness/treatment for another illness/injury • Med on time/route/dose • Wrong chemo/isotope/transfusion

9. Error: Systemic Nature • In the setting of local “environmental factors” • “Active errors” of individuals converge and interact with…

10. Error: Systemic Nature • “Latent conditions” to increase likelihood that: • individuals will make errors, and • errors will cause harm

11. Recognition • Errors are underreported • Problems • Errors of omission not easily recognized • Recognized errors require too much paperwork

12. Recognition • Hello, I was not sure where to direct my comment, so I am hoping you will be able to address it or forward it on. • I was trying to file an incident report about a blood culture that was not drawn in the middle of the night, but found the online form was very onerous and time consuming.  Eventually I gave up. • There are many small errors that happen on the floors, and I imagine only a tiny fraction are reported.  I fear that with the new form that takes so long to fill out and involves disabling a pop-up blocker, etc, too few incidents will be reported.  (Medical resident, major metropolitan hospital.).

13. Understanding Errors: concepts • Poor communication • Poor teamwork • Diffusion of responsibility • System vs personal responsibility

14. Understanding Errors: concepts • Human factors • Tolerance of ambiguity • Culture of low expectations

15. Communication Failure of communication RN consultant attending resident patient

16. Highly functioning teams: • Communicate well • Allocate role responsibility clearly • Train to back up team members as necessary

17. Highly functioning teams: • Monitor team members performance • Resolve conflicts efficiently • Use well designed protocols/procedures to assure complex tasks are executed flawlessly

18. Teamwork • Pilots vs. surgeons: • Acknowledge effect of fatigue (64 vs. 18%) on performance • Agree junior team members should be free to question decisions of seniors (97% vs. 55%) • Sexton JB et al. Error, stress, and teamwork in medicine and aviation: cross sectional surveys • BMJ. 2000; 320: 745-9

19. Diffusion of Responsibility • No one is specifically accountable for specific results: “the team” is accountable. • Everyone accountable = no one accountable.

20. System vs personal responsibility

21. Human Factors Human performance can be improved but not perfected: • fatigue • memory limitation

22. Ambiguity and Workarounds • High performing organizations • prevent problems form producing further consequences once they occur, and then • prevent their recurrence

23. Differences between error-prone and high-performing organizations Design and execution of work Response to problems Consequences

24. Error-prone organizations • Error prone organizations tolerate ambiguity: a lack of clarity about what is expected to happen when work proceeds. • When problems are recognized they are worked around.

25. Error-prone Organizations • Unclear before work begins what is expected to happen. • People do what is necessary to “get the job done”. • No additional attention is drawn to the problem.

26. Error-prone Organizations • The effects of problem propagate • Similar problems recur regularly • Processes improve sporadically

27. High performing organizations • Design work as a series of ongoing experiments. • Consistently specify how to do work. • When specifications deviate from actual experience, investigate promptly.

28. High-performing Organizations • Effects of problems contained • Causes of problems addressed so do not recur • Performance improves continuously

29. Removing ambiguity • What is the workgroup trying to achieve? • Who is responsible for which tasks? • How do we exchange information? materials? services? • How exactly do we perform tasks?

30. Removing ambiguity • Treat discrepancies as something that is “not normal.” • Example: • 23 searches (49 minutes)/shift for narcotic keys. • Assigned numbered keys2895 nurse hours/year saved.

31. Culture of Low Expectations • Expect a norm of faulty and incomplete exchange of information. • Result: interpret “red flags” as mundane repetition of poor communication to which they have become inured.

32. Understanding Errors: concepts • Poor communication • Poor teamwork • Diffusion of responsibility • System vs personal responsibility

33. Understanding Errors: concepts • Human factors • Tolerance of ambiguity • Culture of low expectations

34. Improvement: communication MD/RN leaders explicitly acknowledge that hierarchies within and among professions create barriers to effective exchange of information

35. Improvement: system vs. individual responsibility • No reason to expect punishment of individual will help system failures • Use Reason’s algorithm in formal and informal processes • Prerequisite: open and vigorous discussion

36. Improvement • Prerequisite: open and vigorous discussion • Protocols: • Assign clearly to specific caregivers to carry out specific steps • revised continuously w/ experience • Periodic audits to assess adherence

37. Improvement: human factors “We cannot change the human condition but we can change the conditions under which humans work.” James Reason 1997

38. Improvement: Reduction of ambiguity Your responsibility is to prevent error recurrence, not just to feel bad (which you will anyway)

39. Improvement: reduction of ambiguity • Protocols: • Assign clearly to specific caregivers to carry out specific steps • revised continuously w/ experience • Periodic audits to assess adherence

40. Improvement • Examples: • Specific protocols for communicating vital clinical info when pts spend time on inpt units not specializing in their condition. • Routine standardized verification of pt ID in units performing invasive procedures.

41. Improvement • Start small • Start simple

42. How 911 has changed