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Learning from excellence in critical care

  1. Learning from Excellence Adrian Plunkett, Birmingham UK SMACC June 16th 2016 @adrianplunkett
  2. Source: Eurocontrol. From Safety 1 to Safety 2. A white paper
  3. Trying to understand safety by only looking at incidents is like trying to understand sharks by only looking at shark attacks Attributed to Bob Wears
  4. Theirs nothing worse than misplaced apostrophe’s
  5. 1 + 1 = 2 2 + 2 = 4 3 + 3 = 7 4 + 4 = 8 5 + 5 = 10
  6. Rieger at en.wikipedia derivative work: JohnKiat (talk) derivative work: JohnKiat [CC-BY-SA-3.0 ( or GFDL], via Wikimedia Commons
  7. Negativity culture: Adverse events Error Risk IR1 / Datix SIRI / SUI Never event
  8. Second victim effect Third victim? Fourth victim?
  9. Source: Eurocontrol. From Safety 1 to Safety 2. A white paper
  10. What do people report? No one has reported themselves Reports focus on what was DONE Often ‘motivational > informational’ Many themes
  11. … took her own initiative to design a bespoke care plan on ventilation weaning on a patient with complex needs that is clear for both her colleagues and parents to understand. This meant that everyone involved in this patient's care had a shared mental model
  12. “Great innovation and organisation of the ward-round with a new structure trialled that was more efficient and more enjoyable for the team”
  13. “...during a busy shift ... took the time to communicate with family ... compassion and kindness... the family was comforted and reassured... Empathy, kindness, extremely supportive towards the whole family.”
  14. “...was looking after a patient on PICU. During the morning ward round not only had he spotted a ten fold drug dose error which he flagged for our attention, he also challenged very appropriately and constructively about why a child with a viral infection was on antibiotics.”
  15. 0 10 20 30 40 50 60 70 80 90 100 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Frequency of IR2 reports Outside PICU PICU
  16. PRIP study 0% 20% 40% 60% 80% 100% Pre Post Percentageofprescriptions Study period Effect of positive reporting on prescribing practice Gold standard Not gold standard
  17. Imagine you had three wishes...
  18. “... The two most powerful words in the English language are ‘well done’” Sir Alex Ferguson
  19. “Saying ‘thank you’ or ‘well done’ might be the simplest quality improvement intervention of all” Dr Emma Plunkett

Editor's Notes

  1. Prospect theory We value loss more than gain
  2. Prospect theory We value loss more than gain
  3. Negative effects of looking at the negative pervades our wider society... See the top 10 most read What use are these? These are most read Entertainment... We are attracted to it, good at spotting. Doesn’t it help in healthcare?
  4. Contrary to popular belief and their widespread use in headlines, positive superlatives (i.e., “best”, “always”) do not appear to be compelling to readers. In fact, our data shows just the opposite. For our headline analysis, we drew a sample of approximately 65,000 paid link titles from the pool of all English language paid links that ran in Outbrain’s network between the months of April and July 2012 and measured the impact of superlative use on engagement (click-through rate). As you can see in the graph below, the results were very interesting!   Compared with headlines that contained neither positive (“always” or “best”) nor negative (“never” or “worst”) superlatives, headlines with positive superlatives performed 29% worse and headlines with negative superlatives performed 30% better. The average click-through rate on headlines with negative superlatives was a staggering 63% higher than that of their positive counterparts. These results were replicated in a subsequent headline study that included data from the months of August – September 2012. So why the attraction to the negative and the distaste for the positive? Audience aversion to positive superlatives may simply be a product of overuse, or it could be because readers are skeptical of sources’ motives for endorsement. On the flip side, sources of negative information may be more likely to be perceived as impartial and authentic. Whereas positive superlatives may have become clichéd through overuse, negative superlatives may be more unexpected and intriguing. Want to put these findings to the test? If you’re amplifying your content with Outbrain, try testing out some headlines with negative superlatives in your campaign. Don’t have an Outbrain campaign? Check out our Amplify DIYplatform to see how you can start growing your audience!
  5. Trouble is it generates a negative culture: The language of negativity. IR1 story Why is this?
  6. Common theme.
  7. Innovations are difficult to capture unless you look for them We’ve captured quite a few now via IR2. Workarounds and safety-II
  8. Is this actionable intellgence? Just nice? Show appreciation, more likely to increase motivation. Motivational vs. Informational.
  9. Near miss – positive reporting of near miss, rather than negative reporting Challenge authority gradient Used a example of communication within the unit
  10. Story about name and shame Positive reporting can also be used to improve quality as a driver, rather than negative targets... Good practice increases; error (or bad practice) necessarily decreases. In contrast to the usual approach to QI or safety...