Quality Patient Safety. Quality Patient Safety Lessons from other Industries. Lessons Learned from other Industries

Transcription

1 Lessons from other Industries

2 Or making others best practices yours!

3 Dr. Ken Green Commander, US Navy

4 Personal background: Commander, United States Navy Current assignment as Senior Healthcare Analyst, Clinical Support Division of Medical Operations at the Navy s Bureau of Medicine and Surgery Training & Education: Aviation Safety, Anesthesiology, Dentistry and Bioengineering Navy career for 23 years included 10 years as an Aerospace Physiologist and Aeromedical Safety Officer: Human Factor Analysis of (US Navy) Aircraft Mishaps Aircrew Coordination Instructor for Fighter Aircraft Aircrew / Helicopter Aircrews Founded CounteRisk Technologies, Inc. (January 2000) Using aviation safety principles to train any team or group be it in aviation, medicine or business, in communication, decision making and mishap prevention.

5 Disclaimer Dr. Green is not receiving any funding, compensation or special interest considerations for his discussion on any products or procedures mentioned during the course of this program. Any apparent endorsement of said products are based on his own opinions and not those of the United States Navy.

6 In Real Estate the mantra is location location location

7 For Teams, it s Communication Communication Communication!

8 Why clear and accurate communication is so important

9 A panda walks into a café.. He orders a sandwich, eats it, then draws a gun and fires two shots in the air.

10 Why? Why? asks the confused waiter, as the panda makes towards the exit. The panda produces a badly punctuated wildlife manual and tosses it over his shoulder. I m m a panda, he says, at the door. Look it up.

11 The waiter turns to the relevant entry, and sure enough, finds an explanation.

12 Panda. Large black-and and- white bear-like mammal, native to China. Eats, Shoots and Leaves. From British bestseller, Eats, Shoots and Leaves by Lynne Truss published by Gotham Books

13 2005 Quality Colloquium Talk: The OR as a Cockpit: Human Factor and Aviations for improving Crisis Communication and Decision Making in High Risk Critical Care Situations My talk focused on the history of aviation CRM, and the 1999 IOM report and how aviation safety lessons learned could be easily adapted to improve medicine s best practices to improve medical team communication and decision making in crisis situations.

14 Aviations : Adapting CRM Pre-Flight Briefings Post Flight Debriefs Mishap Investigations Analysis Reporting Includes Near Misses!

15 Medicine s Safety History & Human Factor Threats Medical Mishap Events Institute of Medicine Report To Err is Human (1999) Potentially 44,000 98,000 deaths from medical errors

16 2006 Quality Colloquium Talk: Team Training- Our Inconvenient Truth-Are you participating? the future of CRM and Team Training in Medicine focused on why wouldn t you have a team training program.

17 Military and civilian aviation programs have achieved remarkable improvements in their mishap rates over the last 25+ years following the introduction, and system wide implementation of concerted efforts to target flight teams awareness of human factor threats, communication and decision making skills, and teamwork improvement.

18 Communication errors alone account for over 70% of all patient related medical errors in both Navy and civilian medical practices.

19 CRM programs, and the foundations upon which they are based, have found their way into medical literature and practice worldwide, both at the critical care operating room, intensive care and emergency department levels, as well as within traditional patient care areas.

20 Risks and Opportunities: There are no risks to deploying a program such as this. The benefits of improved team performance, reduced errors and positive successful and predictable patient outcomes, far outweigh any possible financial expenditure for training costs, including travel of master trainers to MTFs to conduct training, and the costs of lost provider time for those participating in training sessions.

21 How should we measure success of these programs? Reduction in Mishap Rates? (long term) Increase in Reported Near Misses? (short term) Decrease in staff conflict issues? (ongoing)

22 2007 Quality Colloquium: Conspicuously absent

23 A Different Perspective about medical teams: When a Doctor is the Patient

24 Aviation Safety in Critical Care Medicine: on my Back One Dr. s s Strangelove- or how I learned to stop worrying and become part of my team

25 At my last lecture, to a group of OR staff, an audience member commented: Dr. Green you sure know a lot about neurocritical care, are you a neurocritical care specialist. No, No, I answered, but I did stay in a Holiday Inn Express last night.

26 COLLABORATION WITH MY DOCTOR A A brief recount of my experiences.

27 COLLABORATION WITH MY DOCTOR My surgeon became interested in the team training I did and had me lecture to his residents and fellow staff He then asked me to collaborate with him on an exciting project he had begun to utilize some advanced telemedicine robotics to reach out and touch patients far away for improving neuro critical care.

28 The remote presence robot, essentially a live action VTC developed ed by In Touch Health ( ), enabled him and others to consult from afar on critical surgical interventions and a other traumatic brain injury issues for wounded warriors injured in Iraq and Afghanistan. He provided the neuro critical expertise while I am trying to bring the team communication issue of using devices such as this to the forefront of improved care and a new best practice.

29 e e x c EXAMPLES a Trail of errors led to 3 wrong brain surgeries Surgeons' ego at R.I. hospital may have led to carelessness, study says PROVIDENCE, R.I. - One operation went awry after an experienced brain surgeon insisted to a nurse he knew what side of the head to operate on but got it wrong. Another time, a doctor-in-training cut into the wrong side of a patient's head after skipping a pre-op checklist. In a third case, the chief resident started brain surgery in the wrong place, and the nurse didn't stop him.

30 Nurses may be afraid to speak up The mistakes at Rhode Island Hospital suggest that the precautions can still be thwarted by the human element ego and overconfidence on the part of surgeons, and timidity on the part of nurses too afraid to speak up when they see something about to go wrong. "There's a big cultural issue in most operating rooms where there's a hierarchical culture there. A surgeon is used to being the captain of the ship, and his or her word goes," said Diane Rydrych, assistant director of the division of health policy at the Minnesota Health Department. "If there's a culture where people are afraid to say anything to the surgeon because they're afraid they're going to get yelled at, that's a problem." Among surgeons, there is a "sense that `I'm very well trained. I've done this procedure 100 times. It's not going to happen to me,'" she said. "Surgeons need that. You don't want an underconfident surgeon operating on you. But that's the downside."

31 Responsibility vs. Protocol (From an actual RCA Analysis): The fact that many members of the health care team including resident physicians and nursing staff recognized the signs of fetal and neonatal compromise is commendable, however it is quite concerning that they felt unable or unwilling to seek other help when the attending physician s unwillingness to intervene became apparent.

32 Responsibility vs. Protocol (RCA continued): It is possible that the rank structure of the military forms an inherent reluctance on the part of junior members to jump the chain of command when confronted with this situation. Likewise the subordinate role of the resident physician relative to the attending physician may impart a similar reluctance. We feel this is the main root cause of the operant event.

33 "The only thing necessary for the triumph of evil is for good men to do nothing." Edmund Burke