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Medical data recorder

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Presentation Medical Data Recorder

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Medical data recorder

  1. 1. Observatie in de OK 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
  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. 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 2008, NIVEL Direct costs are > 125M euro per year
  9. 9. Systemic learning I am always ready to learn although I do not always like to be taught Winston Churchill
  10. 10. © Medical Data Recorder
  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....[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
  12. 12. 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!
  13. 13. 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 Lesson Tenerife
  14. 14. Aviation safety Quality Assurance Patient safety Checklists Procedures Training syllabi communication
  15. 15. Surgical education Improvement begins with I Arnold Glasow
  16. 16. 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)
  17. 17. 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
  18. 18. Stop and count to 10 Think about your options Do what you think is best V V V Checklists
  19. 19. Pause points • Preparation • Team start • Incision • Reach target • Treatment • Repairing • Closing • Hand-over • Risks / abnormalities • Pre-conditions • Postconditions • Checks • Activities }{
  20. 20. (my) Observations • High fault tolerance • Strong hierarchy • Going through the motions of checklists • Attention to standard process • Chasm between disciplines http://www.icrowds.net/2014/01/observatie-in-de-operatiekamer/
  21. 21. 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 ? ? ?
  22. 22. • Collective memory • Shared stories • Evidence based processes • organizational quality • Team focus • Hierarchy • An error does not imply guilt © Medical Data Recorder Lessonsforsurgery
  23. 23. Medical Data Recorder Facts do not cease to exist because they are ignored. Aldous Huxley
  24. 24. More than 50% of operation reports do not describe what really happened
  25. 25. LearningProsecution
  26. 26. Vision&and& sound Data&from& sensors Tagging activities
  27. 27. S ASSNCN A AA Camera Microphone
  28. 28. Thank you Martijn Kriens

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