I MAKE ERRORS….YOU WILL TOO!

1. I MAKE ERRORS….YOU WILL TOO! I’M A FAILURE….YOU CAN BE TOO! Prepared by: Gord Vail, M.Sc., MD Chief of Staff, Hotel-Dieu Grace Hospital Windsor ON

2. DISCLOSURES Advisory Boards ● Hoffman-LaRoche ● Bayer Sponsored Speaker ● Hoffman-LaRoche ● Bayer ● Sanofi-Aventis Educational Grants for HDGH Grand Rounds ● Leo Pharma ● Sanofi-Aventis

3. ERRORS AT WORK • Categories of errors • Examples • Change management • Why it’s difficult • Errors in Administrative Projects

4. QUOTE “A failure is a man who has blundered but is not able to cash in on the experience.” Elbert Hubbard (1856-1915) American author & philosopher

5. GOD SAVE THE THE QUEEN

6. QUESTION What did the last slide say?

7. ATTRIBUTION ERROR ● Or pattern recognition error ● Why did you see something different? ● What conditions occur at work that could make such an error occur? ○ Labeling ○ Location ○ Same patient, day after day… - Chest pain in the ED ○ Old charts ● Our PA example

8. THE TYPICAL INNER-CITY ED PATIENT… • Chronic pain/alcoholic/homeless patient in the hallway • Our PA sees them (unusual) • Finds abnormalities • If one of the attendings with their past experience saw them???

9. AN EXAMPLE CLOSE TO HOME… General surgeon gets a referral • ?Breast cancer • U/S ordered by FMD for ?Breast cancer • U/S report RFR included with referral: ?Breast cancer • U/S guided biopsy for ?Breast cancer • Pathology report RFR: ?Breast cancer What do you think happened? • Actual diagnosis on pathology – NOT breast cancer

10. CONFIRMATION BIAS We try to find data that will support our hypothesis • What gets written on a chart is your interpretation of the interaction What do you ignore in your practice? • “Typical” chest pain • Usual IVDA patient • Psychiatry patients with medical illnesses How can you avoid this? • Truly listen…to the patient and that voice in your head!

11. IMPLEMENTING CHANGE My story • HDGH LEAN Initiatives • Dr. David Ng & I • Leadership • Computerization of the ED What did it show? What learnings came out?

12. WHICH PROJECT SUCCEEDED?

15. WHY IS CHANGE IMPORTANT? “The major problem with planning is that plans are virtually always wrong.” Brown & Eisenhardt 1998 The Emergency department is a fairly stable environment • 1 ICU admit/d, 4 medical, 4 hospitalist, 12% admission rate It’s the long-term issues facing a hospital that change: • Funding • Technology • Care models

16. I’M A FAILURE… YOU’RE GOING TO FAIL… Management projects failure rate = 80% • We have to learn from failure Culture of Blame • If not supportive, who’s going to lead a project doomed to fail? • Why try to lead? • How can you change it? • Do you really think everyone at your hospital wants you & PIP or P4R to succeed? These are the important questions that need to be asked!

17. RESEARCH COMPONENT • Everyone’s involved in before/after scenarios • Not the most rigorous but still useful • Will help others • Our experience with communication • My colleague/friend in telestroke medicine • Always need proof (and more proof!) that something works • Ideas for improvement • Not everything intuitively correct is proven to be so…

18. Target patterns of ten shots fired by two riflemen. A’s pattern exhibits no constant error, but rather large variable errors. B’s pattern shows a large constant error, but small errors. (from Chapanis, 1951).

19. THREE TYPES OF HUMAN ERRORS 1. Skill Based • Slips or lapses, i.e. forgetting your keys in the a.m.! 2. Rule Based • Brain processes • Go back into your experience and find correct response, for example a differential diagnosis for SOB 3. Knowledge Based • Lack of knowledge • Shouldn’t reach the patient • Barriers such as co-signing for clerks/residents James Reason’s Swiss Cheese model from 1990 • Puts up barriers to prevent the error from propagating STAR technique used to assist with prevention • Stop, think, act, review

20. THE SWISS CHEESE MODEL The Swiss cheese model of how defenses, barriers, and safeguards may be penetrated by an accident trajectory.

21. HIERARCHAL ERRORS Usual example to start with is pilots • Who flies? See any relation to medicine? • Who tells on an attending when you’re in training? Cultural change • Errors are talked about • Legislated in Canada about when & how to disclose an error Can work for you • Examples from the leaders filter down • An example from HDGH is Hand washing!

22. PERSON OR SYSTEM APPROACH? Person focuses on the individual • Forgetfulness, inattention or moral weakness System looks at conditions around person’s work • Build defenses to avert or mitigate an error’s effects But, isn’t blaming an individual easier & more satisfying?? • Less institutional responsibility • Less time consuming • No work to fix; just eliminate the individual

23. SUMMARY Leaders in the crowd • Be kind! • Acknowledge your failures and errors; Powerful to those you work with. Think of the big picture • One person made the error that’s going to allow you to rework the system that led to the error; Difficult to do but necessary Keep trying things • Hit that 20% goal!

24. THANK YOU! QUESTIONS OR COMMENTS?