Challenges to Learning: Patient Safety Events in Complex systems

1. Challenges to Learning:Patient Safety Events inComplex systems Patient Safety Event Learning Seminar Deer Lodge Centre, Winnipeg, MB November 2, 2010

2. Challenges to Learning: (forget about complex systems) The usual suspects: • Fear of consequences • Fear of the law • Lack of controls (as in cybernetics) • Messy mental models • Learning anaphylaxis

3. Challenges to learning: Fear of consequences Fear of consequences • From the facility – where is the Just and Trusting Culture policy? • From the department – where is the inter-disciplinary support and commitment to learning? • From the unit – what will and won’t be used in performance management assessments? (back to the J+T Culture thing) • From colleagues – how we do things around here?

4. Challenges to learning: Fear of the law Fear of the law: • “Blueprint” for litigation • PHIA-noia • FIPAA-bility • Bogeyman of the criminal charges • Do you like to gamble? (1/13 versus 1/160,000)

5. Challenges to learning: Lack of controls Lack of controls (cybernetics gone wild): • Feedback to staff – why bother reporting? • Feedback to patients/families – why bother trusting? • “Feed forward” to other units – why wash “dirty laundry”? • “Feed forward” to anybody who is interested – the problem of the big bad internet?

6. Challenges to learning: Messy mental models Messy mental models: • Variation of “if it walks like a duck and looks like a duck…” • Using linear (or occasionally epidemiological) models to understand the events • Searching for certainty – “We can’t be sure that the infection led to the patient’s demise, so we can’t consider this a critical incident….” • Homage to Rene Descartes

7. Challenges to learning: Learning anaphylaxis Learning anaphylaxis: • Is the facility a learning organization? • Is the department a learning department? • Is the unity a learning unit? • Three cheers for today’s session!!

8. Challenges to learning: In a complex system Healthcare is a complex system: • Probably a hybrid compared to other complex systems • Open versus closed system • Complex adaptive system (NDS) – dynamic nature • Complex socio-technical (or T-S) system – love the technical stuff • Basically a mysterious beast – the case of the dog that didn’t bark in the night…

9. Challenges to learning: In a complex system Some surprising elements: • Nonlinear causation • Emergent versus resultant properties • The importance of context – holistic approach • The system has a history • Relationships between components more important than the components themselves

10. Challenges to learning: In a complex system All of this requires: • Different ways of thinking to recognize learning opportunities • Different ways of reviewing/investigating events to promote understanding • Different ways of talking about events to promote active and applicable learning • (Sounds like hard work….it isn’t)

11. Challenges to learning: In a complex system Questions? Contact info: Rob Robson Healthcare system Safety Advisor rrobson@hssa.ca 519-846-2872 1-877-405-9313