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Observatie in de OK
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
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 more against others to know our
failures, than to hold our failures against
ourselves
Multatuli (Dutch writer)
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
Systemic learning
I am always ready to learn
although I do not always like
to be taught
Winston Churchill
© Medical Data Recorder
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
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!
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
Aviation
safety
Quality
Assurance
Patient
safety
Checklists
Procedures
Training syllabi
communication
Surgical education
Improvement begins with I
Arnold Glasow
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)
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
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 / abnormalities
• Pre-conditions
• Postconditions
• Checks
• Activities
}{
(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/
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
? ? ?
• Collective memory
• Shared stories
• Evidence based processes
• organizational quality
• Team focus
• Hierarchy
• An error does not imply guilt
© Medical Data Recorder
Lessonsforsurgery
Medical Data Recorder
Facts do not cease to exist because
they are ignored.
Aldous Huxley
More than 50% of operation reports do not describe what really happened
LearningProsecution
Vision&and&
sound
Data&from&
sensors
Tagging activities
S
ASSNCN
A
AA
Camera
Microphone
Thank you
Martijn Kriens

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Medical data recorder

  • 1. Observatie in de OK Martijn Kriens @martijnkriens, martijn.kriens@icrowds.net The old operating theatre, London
  • 2. Martijn Kriens Medical Data Recorder Research Quality Assurance Pilot @martijnkriens, martijn.kriens@icrowds.net
  • 4. Human Fallibility Truth emerges more readily from error than from confusion Francis Bacon
  • 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.
  • 9.
  • 10. 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
  • 11.
  • 12. Systemic learning I am always ready to learn although I do not always like to be taught Winston Churchill
  • 13. © Medical Data Recorder
  • 14.
  • 15. 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
  • 16. 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!
  • 17. 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
  • 18.
  • 21. 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)
  • 22. 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
  • 23. Stop and count to 10 Think about your options Do what you think is best V V V Checklists
  • 24. Pause points • Preparation • Team start • Incision • Reach target • Treatment • Repairing • Closing • Hand-over • Risks / abnormalities • Pre-conditions • Postconditions • Checks • Activities }{
  • 25. (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/
  • 26.
  • 27. 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 ? ? ?
  • 28. • Collective memory • Shared stories • Evidence based processes • organizational quality • Team focus • Hierarchy • An error does not imply guilt © Medical Data Recorder Lessonsforsurgery
  • 29. Medical Data Recorder Facts do not cease to exist because they are ignored. Aldous Huxley
  • 30.
  • 31. More than 50% of operation reports do not describe what really happened