© Medical Data Recorder
•  Veiliger &
efficiënter The Medical Data Recorder
Martijn Kriens
Martijn.kriens@medarec.com
© Medical Data Recorder
© Medical Data Recorder
© Medical Data Recorder
Schade in het ziekenhuis
Zorggerelateerde schade in 8%
(↑) van alle opnames/jaar:
•  1/3 potentiee...
© Medical Data Recorder
© Medical Data Recorder
© Medical Data Recorder
Two orders of magnitude (100x)
Safete in aviation and hospital
© Medical Data Recorder
•  Sensitive to processes
–  Transparancy, ratio’s
•  No search for simple explanations
–  Challen...
© Medical Data Recorder
•  Sensitive to processes
–  Focus on individual skills …
•  No search for simple explanations
–  ...
© Medical Data Recorder
Back to the basics
Aviation
safety
Quality
Assurance
Patient
safety
Checklists
Procedures
Training...
© Medical Data Recorder
Foundation of quality improvement
© Medical Data Recorder
CRM and MDR
Do
Act CRM
MDR
Assurance in
processes
Improvement of
processes
© Medical Data Recorder
•  Focus on learnings instead of guilt
–  Just Culture
•  Quality of organisation over individual
...
© Medical Data Recorder
•  To be human is to err …
•  “Safe” incident reporting
•  Systemic errors
•  Learning, not prosec...
© Medical Data Recorder
© Medical Data Recorder
Organisational learning
Operation
Physician
Crew Resource
management
Individual
learning
Organisat...
© Medical Data Recorder
Objective analysis
•  Humans have bad memory under pressure
– More than 50% operation report are w...
© Medical Data Recorder
Change of culture
From Individual Hero’s
to a
Learning Organisation
© Medical Data Recorder
© Medical Data Recorder
Integrated analysis
Vision	
  and	
  sound	
  
Data	
  from	
  sensors	
  
Tagging activities
© Medical Data Recorder
Voet	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  Operatietafel	
  	
  	
  	
  	
  	
  	...
© Medical Data Recorder
•  Independent and safe
–  No connection to EPD
–  No data to IGZ
–  Secure storage
–  Only used f...
© Medical Data Recorder
Questions?
Martijn Kriens
Martijn.kriens@medarec.com
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Presentatie Medical Data Recorder St. Anna Ziekenhuis Geldrop

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Presentatie Medical Data Recorder St. Anna Ziekenhuis Geldrop

  1. 1. © Medical Data Recorder •  Veiliger & efficiënter The Medical Data Recorder Martijn Kriens Martijn.kriens@medarec.com
  2. 2. © Medical Data Recorder
  3. 3. © Medical Data Recorder
  4. 4. © Medical Data Recorder Schade in het ziekenhuis Zorggerelateerde schade in 8% (↑) van alle opnames/jaar: •  1/3 potentieel vermijdbaar •  10.000 pat/jr: potentieel vermijdbaar blijvend letstel •  50% van alle potentieel vermijdbare schade: zorgverlener gerelateerd •  Snijdende specialismen: 62% alle zorggerelateerde schade, waarvan de helft binnen de chirurgie •  Chirurgie: 40% (↑) alle potentieel vermijdbare schade Monitor zorggerelateerde schade 2008 Professor Cordula Wagner
  5. 5. © Medical Data Recorder
  6. 6. © Medical Data Recorder
  7. 7. © Medical Data Recorder Two orders of magnitude (100x) Safete in aviation and hospital
  8. 8. © Medical Data Recorder •  Sensitive to processes –  Transparancy, ratio’s •  No search for simple explanations –  Challenge beliefs •  Preoccupation with failure –  Where does it work better •  Expertise instead of hierarchy –  Open channels •  Resilience –  Clear why High reliability organisations 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
  9. 9. © Medical Data Recorder •  Sensitive to processes –  Focus on individual skills … •  No search for simple explanations –  This is how we do it •  Preoccupation with failure –  Forget failures, move on •  Expertise instead of hierarchy –  The surgeon knows best •  Resilience –  Tradition Medical professionals (negative view …)
  10. 10. © Medical Data Recorder Back to the basics Aviation safety Quality Assurance Patient safety Checklists Procedures Training syllabi communication
  11. 11. © Medical Data Recorder Foundation of quality improvement
  12. 12. © Medical Data Recorder CRM and MDR Do Act CRM MDR Assurance in processes Improvement of processes
  13. 13. © Medical Data Recorder •  Focus on learnings instead of guilt –  Just Culture •  Quality of organisation over individual –  Organisational learning, Crew Resource Management •  Objective data and analysis –  Medical Data Recorder Foundation
  14. 14. © Medical Data Recorder •  To be human is to err … •  “Safe” incident reporting •  Systemic errors •  Learning, not prosecution •  Gross negligence remains punishable –  Honest mistakes not Just culture punitive blame free safety
  15. 15. © Medical Data Recorder
  16. 16. © Medical Data Recorder Organisational learning Operation Physician Crew Resource management Individual learning Organisational learning Medical Data Recorder
  17. 17. © Medical Data Recorder Objective analysis •  Humans have bad memory under pressure – More than 50% operation report are wrong •  Multiple perspectives – Anesthesiologist, nurse, surgeon, ..
  18. 18. © Medical Data Recorder Change of culture From Individual Hero’s to a Learning Organisation
  19. 19. © Medical Data Recorder
  20. 20. © Medical Data Recorder Integrated analysis Vision  and  sound   Data  from  sensors   Tagging activities
  21. 21. © Medical Data Recorder Voet                            Operatietafel                              Kop CARRÉCONSTRUCTIE C4 C1 C2 C3 BP Anesthesie  1 Anesthesie  2 BP BP C  1-­‐4:            camera’s  1  t/m  4 BP:                    extra  bevestigingspunt BP Time-­‐out  /  Briefing
  22. 22. © Medical Data Recorder •  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 Core issues implementation in hospital
  23. 23. © Medical Data Recorder Questions? Martijn Kriens Martijn.kriens@medarec.com

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