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Presentatie surgical education 2020 bij Radboud

Presentatie surgical education 2020 bij Radboud

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  • 1. Painfull Transparancy Martijn Kriens 14 November 2013
  • 2. Martijn Kriens ! Medical Data Recorder ! Research ! Quality Assurance ! Pilot ! @martijnkriens, martijn.kriens@icrowds.net Business|Science|Government|Innovation|ICT eHealth| Cloud|Pyramids2Pancakes|iCrowds MDR|AIM| RTLnieuws|IIPSaaS|WirelessArnhem Vlieger| Recalcitrant| ....
  • 3. Human Fallibility! ! Systemic learning! ! Surgical education
  • 4. Human Fallibility Truth emerges more readily from error than from confusion ! Francis Bacon
  • 5. TO ERR IS HUMAN
  • 6. TO BE HUMAN IS TO ERR
  • 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. Surgery is responsible for 60% of all Avoidable Errors (22.500) Direct costs are > 125M euro per year 1,8% 1,4% 0,9% 0,5% 0,0% Diagnose Surgical Treatment Medication Care Release Others Monitor Zorggerelateerde Schade 2008, NIVEL
  • 9. Systemic learning I am always ready to learn although I do not always like to be taught ! Winston Churchill
  • 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!
  • 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. 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. Patient safety Aviation safety Checklists Procedures Training syllabi communication Quality Assurance
  • 14. Plan the proces - checklists, … Act on deviations - analise and adapt Do accoording to agreed processes Check expected outcomes with reality
  • 15. Surgical education Improvement begins with I ! Arnold Glasow
  • 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. Assurance in processes Improvement of processes Crew Resource Management (CRM) Medical Data Recorder (MDR) ck e h C Do Act an l P
  • 18. More than 50% of operation reports do not describe what really happened
  • 19. Prosecution Learning
  • 20. High reliability organisations • Sensitive to processes! – • No search for simple explanations! – • Challenge beliefs Where does it work better Expertise instead of hierarchy! – • ????? Preoccupation with failure! – • Transparancy, ratio’s Open channels Resilience! – Clear why 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 Succes Failure
  • 21. • Collective memory! • Shared • stories Evidence based processes! • organizational • © Medical Data Recorder quality Team focus! • Hierarchy • An error does not imply guilt
  • 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. Thank you Martijn Kriens