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Safety in the OR
Martijn Kriens
@martijnkriens, martijn.kriens@icrowds.net
The old operating theatre, London
Martijn Kriens
Medical Data Recorder
Research
Quality Assurance
Pilot
@martijnkriens, martijn.kriens@icrowds.net
Human Fallibility
Systemic learning
Medical Data Recorder
Entrepreneurship in healthcare
Human Fallibility
Truth emerges more readily from
error than from confusion
Francis Bacon
TO HUMANISERR
TO BE HUMAN IS TO ERR
We nemen het anderen meer kwalijk dat ze onze fouten kennen, dan
onszelf dat wij daaraan mank gaan.
Multatuli
We hold it m...
10-2
10-3
10-4
10-5
10-6
10-7
Himalaya mounteneering (3x10-2)
Aviation (6x10-7)
10-2
10-3
10-4
10-5
10-6
10-7
Himalaya mountaineering (3x10-2)
Aviation (6x10-7)
Hospital (6x10-4)
Amalberti
1,6%
970
126M
1. (Vrijwel) geen aanwijzingen
2. Geringe aanwijzingen
3. minder dan 50-50 maar ‘close call’
4. meer dan 50-50 maar ‘close...
0,0%
0,4%
0,8%
1,2%
1,6%
Diagnose Surgical Treatment Medication Care Release Others
2004
2008
2012
Surgery is responsible ...
Systemic learning
I am always ready to learn
although I do not always like
to be taught
Winston Churchill
Small errors, serious consequences
Split second decisions
Individual skills and teamwork
I know a lot of doctors who became recreational pilots, but
I don’t know one pilot who became a recreational doctor.
http:...
Tenerife
27 Maart
1977
17:06:50
KLM (RADIO) Ah roger, sir, we are cleared to the Papa Beacon flight level nine
zero until intercepting the three two five. W...
KLM (RADIO) Ah roger, sir, we are cleared to the Papa Beacon flight level nine
zero until intercepting the three two five. W...
PLANE1234: [call sign] ready for departure at Runway three zero
TOWER: [call sign], you are cleared for take off Runway th...
Education
Improvement begins with I
Arnold Glasow
Aviation
safety
Quality
Assurance
Patient
safety
Checklists
Procedures
Training syllabi
communication
Not Received 7%Not Transmitted 49% Misunderstanding 44%
Patterns of Communication Breakdowns Resulting in Injury to Surgic...
Blood pressure
is 60!
Fuck off and
concentrate on your
own job
(my) Observations
• High fault tolerance
• Strong hierarchy
• Going through the motions of checklists
• Chasm between disc...
Plan
Do
Check
Act
Crew
Resource
Management
(CRM)
Medical
Data
Recorder
(MDR)
Assurance in
processes
Improvement of
process...
Central line checklist
1. Wash your hands with soap.
1. Clean the patient’s skin with chlorhexidine
antiseptic.
2. Put ste...
Stop and count to 10
Think about your options
Do what you think is best
V
V
V
Checklists
Pause points
• Preparation
• Team start
• Incision
• Reach target
• Treatment
• Repairing
• Closing
• Hand-over
• Risks / ...
Is your name Pietje Puk?
Is urine produced?
Does your left kidney needs to be removed?
Multiple questions, one answer
….
Q...
“My Aircraft”
“Your Aircraft”
Retirement age
Surgical instruments
Open communication
Hierarchies
…
Examples of barriers
Safety culture
45% of surgeons think junior team members
should not question decisions compared to 6%
of pilots
70% of sur...
Reporting errors
50% find it difficult to report errors
reasons of underreporting
personal reputation (75%)
Claims (71%)
Exp...
1. Compensate quickly and
fairly when unreasonable
medical care causes injury.
2. Defend medically
reasonable care vigorou...
Safety culture
• Reporting culture
• Just culture
• Flexible culture
• Learning culture
Informed culture
}
James Reason: M...
Reporting culture
• Indemnity for honest mistakes
• Confidentiality
• Separation of analysis and authority
• Timely and rel...
Just culture
• Intentions - actions - consequences
• Negligence, criminal intent
• Honest mistakes
• Learning over prosecu...
Flexible culture
• Strict organisation of default processes
• Ability to switch from top down to bottom up
• Risk aware
Sh...
Fewer planes crash when
the co-pilot is flying…
Learning culture
• Observing, reflecting, creating, acting
• Priority on proces
Implementation
Unsafe acts Workplace Organization
Active failures and Latent conditions
Unsafe acts Workplace Organization
Active failures and Latent conditions
Non-Technical skills
• Situational awareness
• Gathering information, Understanding information, Projecting
and anticipati...
AnticipationContaiment
• Preoccupation with failure
• Actively find failures and learn
• Reluctance to simplify
– Challenge...
Errors are seen as
consequences instead as
causes
• Collective memory
• Shared stories
• Evidence based processes
• organizational quality
• Team focus
• Hierarchy
• An err...
Things that never
happened before
happen all the
time
Scott D. Sagan
The limits of safety
Medical Data Recorder
Facts do not cease to exist because
they are ignored.
Aldous Huxley
LearningProsecution
There is no evidence to suggest …
Vision	and	
sound
Data	from	
sensors
Tagging activities
S
ASSNCN
A
AA
Camera
Microphone
MeDaRec
Entreneurship
Success is stumbling from failure to failure
with no loss of enthusiasm.”
Winston Churchill
2009: start ReMarketable
2010: idea for OR black box
2010: 1st Contact RadboudUMC
2013: Trial in animal OR
2014: Agreement...
Thank you!
Martijn Kriens
martijn.kriens@icrowds.net
Safety Culture
External forces
• Production pressures
• Visibility of accidents for the general public
• Can it happen to everyone or onl...
%
Safety thinking
Evidence based Safety culture
Defences
• Understanding and awareness
• Guidance
• Alarms and warnings
• Restore
• Containment
• Escape and rescue
Barriers
• the need to limit the discretion of workers
• the need to reduce worker autonomy
• the need to make the transit...
Risks
Known un-knowns
(meta instructions (think!))
“If .. stop and think”
Known knowns
(training, checklists, ..)
“Do this...
Dimensions
• type of expected performance
• from daily routine work to highly innovative, and standardized or repetitive
•...
“A lot of you are going to have to make decisions above
your level. Make the best decision that you can with the
informati...
Non-technical skills
Non-technical skills are decision
making and interpersonal skills
needed to work together as a team
93
94
9514
From	individual	heros	
to	a	
Learning	organiza4on
• To be human is to err …
• “Safe” incident reporting
• Systemic errors
• Learning, not prosecution
• Gross negligence rem...
Two orders of magnitude (100x)
1 incident
=
10 “almost”- incidents
(plenty of oppurtunity to learn)
Communication
Hurdles of communication
Meant
Said
Heard
Understood
Said
Heard
Understood
Done
≠
≠
≠
≠
Rall M, Gaba D. Human performance ...
“operate by voice”
“Perhaps we need to intubate”
“what are we missing”
Meant is not said
Said is not heard
Mumbling
“….”
“I think I am going to”
Heard is not understood
“Stop and Listen”
“My Patient”, “Your Patient”
Read-back
Missing meaning due to multi-tasking
“May...
Understood is not done
“Report when done”
“do this”
Situation
“Blood pressure is below 60”
Background
“Life signs are critical”
Assessment
“Extensive blood loss will lead to ...
Citing names
Sandra
Clear instructions
Check for bleeding on the left
Closed loop
Report when finished
High Reliability Organisations
• Team Leadership
• Backup Behavior
• Mutual performance monitoring
• Communication adaptability
• Shared mental models
• ...
• hypercomplexity
• tightly coupled
• extreme hierarchical (role) differentiation
• many decision makers working in comple...
Adverse events
3,7% adverse events (3,2 to 4,2)
27,6% of adverse events are preventable (22,5 to 32,6)
70,5% > 6 month, 2,6% permanent, 1...
Safety culture
Act
lessons learned
adaption to instruments
analyses of outcomes
analysis of processes
Check
observation
Do...
Plan the proces
- checklists, … Do accoording to
agreed processes
Check expected
outcomes with
reality
Act on deviations
-...
Cabana, M., Rand, C., & Powe, N. (1999). Why Don’t Physicians Follow Clinical Practice Guidelines?
Gut feeling
Task management
Teamwork
Leadership
1. The team leader let the team know what was expected of them through
dir...
we do well
we could do more of
we could do less of
One thing
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Lecture MDR VU

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Lecture for VU on patient safety in the OR and the Medical Data Recorder

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Lecture MDR VU

  1. 1. Safety in the OR Martijn Kriens @martijnkriens, martijn.kriens@icrowds.net The old operating theatre, London
  2. 2. Martijn Kriens Medical Data Recorder Research Quality Assurance Pilot @martijnkriens, martijn.kriens@icrowds.net
  3. 3. Human Fallibility Systemic learning Medical Data Recorder Entrepreneurship in healthcare
  4. 4. Human Fallibility Truth emerges more readily from error than from confusion Francis Bacon
  5. 5. TO HUMANISERR
  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. 10-2 10-3 10-4 10-5 10-6 10-7 Himalaya mounteneering (3x10-2) Aviation (6x10-7)
  9. 9. 10-2 10-3 10-4 10-5 10-6 10-7 Himalaya mountaineering (3x10-2) Aviation (6x10-7) Hospital (6x10-4) Amalberti
  10. 10. 1,6% 970 126M
  11. 11. 1. (Vrijwel) geen aanwijzingen 2. Geringe aanwijzingen 3. minder dan 50-50 maar ‘close call’ 4. meer dan 50-50 maar ‘close call’ 5. Sterke aanwijzingen 6. (Vrijwel) zeker aanwijzingen Vermijdbaarheid van schade
  12. 12. 0,0% 0,4% 0,8% 1,2% 1,6% Diagnose Surgical Treatment Medication Care Release Others 2004 2008 2012 Surgery is responsible for 60% of all Avoidable Errors (22.500) Monitor Zorggerelateerde Schade 2012, NIVEL Direct costs are > 126M euro per year
  13. 13. Systemic learning I am always ready to learn although I do not always like to be taught Winston Churchill
  14. 14. Small errors, serious consequences Split second decisions Individual skills and teamwork
  15. 15. I know a lot of doctors who became recreational pilots, but I don’t know one pilot who became a recreational doctor. http://skepticalscalpel.blogspot.nl/2011/01/surgeons-are-not-pilots.html
  16. 16. Tenerife 27 Maart 1977 17:06:50
  17. 17. 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
  18. 18. 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!
  19. 19. 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 Lessons Tenerife
  20. 20. Education Improvement begins with I Arnold Glasow
  21. 21. Aviation safety Quality Assurance Patient safety Checklists Procedures Training syllabi communication
  22. 22. Not Received 7%Not Transmitted 49% Misunderstanding 44% Patterns of Communication Breakdowns Resulting in Injury to Surgical Patients, Greenberg, 2007 Failures due to communication errors (60 out of 258)
  23. 23. Blood pressure is 60! Fuck off and concentrate on your own job
  24. 24. (my) Observations • High fault tolerance • Strong hierarchy • Going through the motions of checklists • Chasm between disciplines • Unreliable documentation http://www.icrowds.net/2014/01/observatie-in-de-operatiekamer/
  25. 25. Plan Do Check Act Crew Resource Management (CRM) Medical Data Recorder (MDR) Assurance in processes Improvement of processes Plan the proces - checklists, … Do according to agreed processes Check expected outcomes with reality Act on deviations - analise and adapt
  26. 26. Central line checklist 1. Wash your hands with soap. 1. Clean the patient’s skin with chlorhexidine antiseptic. 2. Put sterile drapes over the entire patient. 3. Wear a sterile mask, hat, gown and gloves. 4. Put a sterile dressing over the catheter site. Berenholtz, S. M., Pronovost, P. J., Lipsett, P. a., Hobson, D., Earsing, K., Farley, J. E., … Perl, T. M. (2004). Eliminating catheter-related bloodstream infections in the intensive care unit*. Critical Care Medicine, 32(10), 2014–2020
  27. 27. Stop and count to 10 Think about your options Do what you think is best V V V Checklists
  28. 28. Pause points • Preparation • Team start • Incision • Reach target • Treatment • Repairing • Closing • Hand-over • Risks / abnormalities • Pre-conditions • Postconditions • Checks • Activities }{
  29. 29. Is your name Pietje Puk? Is urine produced? Does your left kidney needs to be removed? Multiple questions, one answer …. Questions
  30. 30. “My Aircraft” “Your Aircraft”
  31. 31. Retirement age Surgical instruments Open communication Hierarchies … Examples of barriers
  32. 32. Safety culture 45% of surgeons think junior team members should not question decisions compared to 6% of pilots 70% of surgeons say they have no averse effect of fatigue compared to 26% of pilots 62% of surgeons rate teamwork with anaesthetists high compared to 42% of anaesthetists with surgeons Error, stress, and teamwork in medicine and aviation: cross sectional surveys J Bryan Sexton, Eric J Thomas, Robert L Helmreich, 2000
  33. 33. Reporting errors 50% find it difficult to report errors reasons of underreporting personal reputation (75%) Claims (71%) Expectations of surroundings (68%) Error, stress, and teamwork in medicine and aviation: cross sectional surveys J Bryan Sexton, Eric J Thomas, Robert L Helmreich, 2000
  34. 34. 1. Compensate quickly and fairly when unreasonable medical care causes injury. 2. Defend medically reasonable care vigorously 3. Reduce patient injuries (and therefore claims) by learning from patients’ experiences. Boothman, R., & Blackwell, A. (2009). A better approach to medical malpractice claims? The University of Michigan experience. Journal of health & life sciences law, 2(2) • 50% less judicial costs • From 20 to 8 months University of Michigan claims
  35. 35. Safety culture • Reporting culture • Just culture • Flexible culture • Learning culture Informed culture } James Reason: Managing the risks of organizational accidents
  36. 36. Reporting culture • Indemnity for honest mistakes • Confidentiality • Separation of analysis and authority • Timely and relevant feedback • Ease of reporting Trust
  37. 37. Just culture • Intentions - actions - consequences • Negligence, criminal intent • Honest mistakes • Learning over prosecution Balance
  38. 38. Flexible culture • Strict organisation of default processes • Ability to switch from top down to bottom up • Risk aware Shared stories
  39. 39. Fewer planes crash when the co-pilot is flying…
  40. 40. Learning culture • Observing, reflecting, creating, acting • Priority on proces Implementation
  41. 41. Unsafe acts Workplace Organization Active failures and Latent conditions
  42. 42. Unsafe acts Workplace Organization Active failures and Latent conditions
  43. 43. Non-Technical skills • Situational awareness • Gathering information, Understanding information, Projecting and anticipating future state • Decision making • Considering options, Selecting and communicating options, Implementing and reviewing decisions • Communication and teamwork • Exchanging information, Establishing a shared understanding, Coordinating team activities • Leadership • Setting and maintaining standards, Supporting others, Coping with pressure NOTSS handbook 1.2, 2006
  44. 44. AnticipationContaiment • Preoccupation with failure • Actively find failures and learn • Reluctance to simplify – Challenge beliefs, don’t stop asking why • Sensitivity to operations • 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-to- hardwire-each-in-your-organization.html?goback=%2Egde_4877284_member_240196966 High reliability organisations Failure Succes ? ? ?
  45. 45. Errors are seen as consequences instead as causes
  46. 46. • Collective memory • Shared stories • Evidence based processes • organizational quality • Team focus • Hierarchy • An error does not imply guilt © Medical Data Recorder Lessonsforsurgery
  47. 47. Things that never happened before happen all the time Scott D. Sagan The limits of safety
  48. 48. Medical Data Recorder Facts do not cease to exist because they are ignored. Aldous Huxley
  49. 49. LearningProsecution
  50. 50. There is no evidence to suggest …
  51. 51. Vision and sound Data from sensors Tagging activities
  52. 52. S ASSNCN A AA Camera Microphone
  53. 53. MeDaRec
  54. 54. Entreneurship Success is stumbling from failure to failure with no loss of enthusiasm.” Winston Churchill
  55. 55. 2009: start ReMarketable 2010: idea for OR black box 2010: 1st Contact RadboudUMC 2013: Trial in animal OR 2014: Agreement Justice department & Inspection 2015: first 10 takes in RadboudUMC 2016: Start UMCG?
  56. 56. Thank you! Martijn Kriens martijn.kriens@icrowds.net
  57. 57. Safety Culture
  58. 58. External forces • Production pressures • Visibility of accidents for the general public • Can it happen to everyone or only a small group • Can we depend on our skills
  59. 59. % Safety thinking Evidence based Safety culture
  60. 60. Defences • Understanding and awareness • Guidance • Alarms and warnings • Restore • Containment • Escape and rescue
  61. 61. Barriers • the need to limit the discretion of workers • the need to reduce worker autonomy • the need to make the transition from a craftsmanship mindset to that of equivalent actors • the need for system-level (senior leadership) arbitration to optimize safety strategies • the need for simplification Editors, S., Barach, P., Amalberti, R., Auroy, Y., & Berwick, D. (2005). Improving Patient Care Five System Barriers to Achieving Ultrasafe Health Care.
  62. 62. Risks Known un-knowns (meta instructions (think!)) “If .. stop and think” Known knowns (training, checklists, ..) “Do this” Un-known knowns (implicit culture) “This is how we do it” Un-known un-knowns (resilience) “Do not take anything for granted” Do we know the risk? Do we know how to deal with the risk?
  63. 63. Dimensions • type of expected performance • from daily routine work to highly innovative, and standardized or repetitive • interface of health care providers with patients • from full autonomy to full supervision • type of regulations • from few recommendations to full specification of regulations at an international level • pressure for justice after an accident • from little judicial scrutiny to routine lawsuits against people and systems • supervision and transparency by media and people in the street of the activity • from little concern to high demand for national supervision Editors, S., Barach, P., Amalberti, R., Auroy, Y., & Berwick, D. (2005). Improving Patient Care Five System Barriers to Achieving Ultrasafe Health Care.
  64. 64. “A lot of you are going to have to make decisions above your level. Make the best decision that you can with the information that’s available to you at the time, and, above all, do the right thing” Lee Scott, CEO Walmart (day before Katrina)
  65. 65. Non-technical skills Non-technical skills are decision making and interpersonal skills needed to work together as a team
  66. 66. 93
  67. 67. 94
  68. 68. 9514 From individual heros to a Learning organiza4on
  69. 69. • To be human is to err … • “Safe” incident reporting • Systemic errors • Learning, not prosecution • Gross negligence remains punishable – Honest mistakes not punitive blame free safety
  70. 70. Two orders of magnitude (100x)
  71. 71. 1 incident = 10 “almost”- incidents (plenty of oppurtunity to learn)
  72. 72. Communication
  73. 73. Hurdles of communication Meant Said Heard Understood Said Heard Understood Done ≠ ≠ ≠ ≠ Rall M, Gaba D. Human performance and patient safety. In: Miller R, editor. Miller's Anesthesia. Philadelphia: Elsevier Churchill Living- stone; 2005. p. 3021-72.
  74. 74. “operate by voice” “Perhaps we need to intubate” “what are we missing” Meant is not said
  75. 75. Said is not heard Mumbling “….” “I think I am going to”
  76. 76. Heard is not understood “Stop and Listen” “My Patient”, “Your Patient” Read-back Missing meaning due to multi-tasking “Maybe I should”
  77. 77. Understood is not done “Report when done” “do this”
  78. 78. Situation “Blood pressure is below 60” Background “Life signs are critical” Assessment “Extensive blood loss will lead to a dangerous situation” Recommendation “Do not proceed”
  79. 79. Citing names Sandra Clear instructions Check for bleeding on the left Closed loop Report when finished
  80. 80. High Reliability Organisations
  81. 81. • Team Leadership • Backup Behavior • Mutual performance monitoring • Communication adaptability • Shared mental models • Mutual trust • Team orientation Baker, D. P., Day, R., & Salas, E. (2006). Teamwork as an essential component of high-reliability organizations. Health services research, 41(4 Pt 2), 1576–98
  82. 82. • hypercomplexity • tightly coupled • extreme hierarchical (role) differentiation • many decision makers working in complex communication networks • high degree of accountability • frequent, im- mediate feedback regarding decisions • compressed time factors • synchronized outcomes Charactaristics HRO’s
  83. 83. Adverse events
  84. 84. 3,7% adverse events (3,2 to 4,2) 27,6% of adverse events are preventable (22,5 to 32,6) 70,5% > 6 month, 2,6% permanent, 13,6% death Harvard Medical Practice Study, 1991 (records from 1984)
  85. 85. Safety culture Act lessons learned adaption to instruments analyses of outcomes analysis of processes Check observation Do Plan checklists training syllabi formal communication
  86. 86. Plan the proces - checklists, … Do accoording to agreed processes Check expected outcomes with reality Act on deviations - analise and adapt
  87. 87. Cabana, M., Rand, C., & Powe, N. (1999). Why Don’t Physicians Follow Clinical Practice Guidelines?
  88. 88. Gut feeling Task management Teamwork Leadership 1. The team leader let the team know what was expected of them through direction and comma 2. The team leader maintained a global prospect 3. The team communicated effectively 4. The team worked together to complete tasks in a timely manner 5. The team acted with composure and control 6. The team morale was positive 7. The team adapted to changing situations 8. The team monitored and reassessed the situation 9. The team anticipated potential actions 10.The team prioritized tasks 11.The team followed approved standards/guidelines Total 12.global rating Cooper, S., Cant, R., Porter, J., Sellick, K., Somers, G., Kinsman, L., & Nestel, D. (2010). Rating medical emergency teamwork performance: development of the Team Emergency Assessment Measure (TEAM). Resuscitation, 81(4), 446–52.
  89. 89. we do well we could do more of we could do less of One thing

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