Medical data recorder v3

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Medical data recorder v3

  1. 1. Painfull Transparancy Martijn Kriens 14 November 2013
  2. 2. Martijn Kriens ! Medical Data Recorder ! Research ! Quality Assurance ! Pilot ! @martijnkriens, martijn.kriens@icrowds.net
  3. 3. Human Fallibility! ! Systemic learning! ! Surgical education
  4. 4. Human Fallibility Truth emerges more readily from error than from confusion ! Francis Bacon
  5. 5. TO ERR IS HUMAN
  6. 6. TO BE HUMAN IS TO ERR
  7. 7. We nemen het anderen meer kwalijk dat ze onze fouten kennen, dan onszelf dat wij daaraan mank gaan. ! Multatuli ! ! We hold it more against others to know our failures, than to hold our failures against ourselves! ! Multatuli (Dutch writer)!
  8. 8. Surgery is responsible for 60% of all Avoidable Errors (22.500) Direct costs are > 125M euro per year 1,6% 2004 2008 2012 1,2% 0,8% 0,4% 0,0% Diagnose Surgical Treatment Medication Care Release Others Monitor Zorggerelateerde Schade 2008, NIVEL
  9. 9. Systemic learning I am always ready to learn although I do not always like to be taught ! Winston Churchill
  10. 10. KLM (RADIO) Ah roger, sir, we are cleared to the Papa Beacon flight level nine zero until intercepting the three two five. We are now at take-off
 …
 
 TENERIFE TOWER OK....[static noise]
 ... (KLM initiates take-off) 
 TENERIFE TOWER Ah, papa alpha one seven three six report the runway clear.
 
 PAN AM (RADIO) OK, will report when we're clear.
 ... 
 KLM FLT ENGR (CVR) [Is he not clear, that Pan American?]
 
 KLM CAPTAIN (CVR) [Oh yes. - emphatic]
 [Pan Am captain sees landing lights of KLM Boeing at approx. 700 m]
 PAN AM CAPTAIN There he is ... look at him. Goddamn that son-of-a-bitch is coming! http://planecrashinfo.com/cvr770327.htm
  11. 11. KLM (RADIO) Ah roger, sir, we are cleared to the Papa Beacon flight level nine zero until intercepting the three two five. We are now at take-off
 …
 
 TENERIFE TOWER OK....Stand by for take-off, I will call you.! ... (KLM initiates take-off) 
 TENERIFE TOWER Ah, papa alpha one seven three six report the runway clear.
 
 PAN AM (RADIO) OK, will report when we're clear.
 ... 
 KLM FLT ENGR (CVR) [Is he not clear, that Pan American?]
 
 KLM CAPTAIN (CVR) [Oh yes. - emphatic]
 [Pan Am captain sees landing lights of KLM Boeing at approx. 700 m]
 PAN AM CAPTAIN There he is ... look at him. Goddamn that son-of-a-bitch is coming!
  12. 12. Lesson Tenerife PLANE1234: [call sign] ready for departure at Runway three zero! ! TOWER: [call sign], you are cleared for take off Runway three zero! ! PLANE5678: [call sign] Runway vacated
  13. 13. Patient safety Aviation safety Checklists Procedures Training syllabi communication Quality Assurance
  14. 14. Plan the proces - checklists, … Act on deviations - analise and adapt Do accoording to agreed processes Check expected outcomes with reality
  15. 15. Surgical education Improvement begins with I ! Arnold Glasow
  16. 16. Failures due to communication errors (60 out of 258) Not Transmitted 49% Misunderstanding 44% Not Received 7% Patterns of Communication Breakdowns Resulting in Injury to Surgical Patients, Greenberg, 2007
  17. 17. Assurance in processes Improvement of processes Crew Resource Management (CRM) Medical Data Recorder (MDR) ck e h C Do Act an l P
  18. 18. More than 50% of operation reports do not describe what really happened
  19. 19. Prosecution Learning
  20. 20. High reliability organisations Preoccupation with failure! • Anticipation • – Challenge beliefs, don’t stop asking why ? ? ? Sensitivity to operations! • • Contaiment Actively find failures and learn Reluctance to simplify! • Succes Failure Grasp context and flow Commitment to resilience! • • Discipline, know what is important Deference to expertise! • – Open channels http://www.beckershospitalreview.com/hospital-management-administration/5-traits-of-high-reliability-organizations-how-tohardwire-each-in-your-organization.html?goback=%2Egde_4877284_member_240196966
  21. 21. Lessons for surgery • Collective memory! • Shared • stories Evidence based processes! • organizational • © Medical Data Recorder quality Team focus! • Hierarchy • An error does not imply guilt
  22. 22. We nemen het anderen meer kwalijk dat ze onze fouten kennen, dan onszelf dat wij daaraan mank gaan. ! Multatuli ! ! We hold it more against others to know our failures, than to hold our failures against ourselves! ! Multatuli (Dutch writer)!
  23. 23. Medical Data Recorder Facts do not cease to exist because they are ignored. ! Aldous Huxley
  24. 24. Data  from   sensors Tagging activities Vision  and   sound
  25. 25. Core issues implementation in hospital Independent and safe! • No connection to EPD • No data to IGZ • Secure storage • Only used for independent research • Integrated and objective! • Indisputable data • Integration of data streams in the timeline • Only to be used for organisational learning! • No Blame • No obsolete data •
  26. 26. S A AA CN SN AS Camera Microphone
  27. 27. Thank you Martijn Kriens

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