Presentatie Medical Data Recorder St. Anna Ziekenhuis Geldrop
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This document discusses using a Medical Data Recorder (MDR) system to improve patient safety and organizational learning in hospitals. It notes that up to 8% of hospital admissions experience care-related harm, with around 1/3 being potentially preventable. Aviation safety practices like checklists, crew resource management, and a focus on process transparency and failure analysis could help hospitals achieve 100x lower error rates. An MDR system could integrate video, sensor, and tag data to provide an objective record of surgical procedures and other care activities to support analysis without individual blame. This would help hospitals shift culture from focusing on individual heroes to organizational learning and continuous safety improvement.
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Presentatie Medical Data Recorder St. Anna Ziekenhuis Geldrop
- 1. © Medical Data Recorder • Veiliger & efficiënter The Medical Data Recorder Martijn Kriens Martijn.kriens@medarec.com
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- 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. © Medical Data Recorder
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- 7. © Medical Data Recorder Two orders of magnitude (100x) Safete in aviation and hospital
- 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. © 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. © Medical Data Recorder Back to the basics Aviation safety Quality Assurance Patient safety Checklists Procedures Training syllabi communication
- 11. © Medical Data Recorder Foundation of quality improvement
- 12. © Medical Data Recorder CRM and MDR Do Act CRM MDR Assurance in processes Improvement of processes
- 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. © 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. © Medical Data Recorder
- 16. © Medical Data Recorder Organisational learning Operation Physician Crew Resource management Individual learning Organisational learning Medical Data Recorder
- 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. © Medical Data Recorder Change of culture From Individual Hero’s to a Learning Organisation
- 19. © Medical Data Recorder
- 20. © Medical Data Recorder Integrated analysis Vision and sound Data from sensors Tagging activities
- 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. © 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. © Medical Data Recorder Questions? Martijn Kriens Martijn.kriens@medarec.com