Making Sense of System- Based Safety

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Making Sense of System- Based Safety Angela Gibbs, Inland Hospital Madeline Orange, Maine Sentinel Event Team Joe Katchick, Maine Sentinel Event Team Jeff Brown, Maine Primary Care Association Patient Safety Organization USM Patient Safety Academy September 29, 2017

1.A System Model 2.Accidents as decision side effects 3.Just culture 4.A case for your review

A system model: people are a system component Institute of Medicine. (2011) Health IT and Patient Safety: Building Safer Systems for Better Care. Pages 59-75. Accessed January 22, 2013. http://www.iom.edu/reports/2011/health-it-and-patient-safety-building-safer- Systems-for-Better-Care.aspx.

A System of Systems: Nested Levels of the U.S. Healthcare System D C Payors Healthcare Organization B A Patient Experience Front-line units Legislation Clinical Space Berwick, D., A User s Manual for the IOM s Quality Chasm Report, http://www.healthaffairs.org; Corrigan, et al., 2001

Accidents as Decision Side Effects Judith s story: Morphine Misadventures BCMA Meets Cost Pressure Patankar, Brown, Treadwell, 2005

D The U.S. Healthcare System s Cascade of Decision Side-effects C A B Clinical Space

Payments D Tort Law Legislation The U.S. Healthcare System s Cascade of Decision Side-effects C Cost Cutting Focus on Efficiency B A Clinical Space

Payments D Tort Law Legislation The U.S. Healthcare System s Cascade of Decision Side-effects C Fragmentation of care processes. Slips Lapses Mistakes... Cost Cutting Focus on Efficiency B Understaffing Time Pressure Fatigue A Clinical Space 11

Payments D Tort Law Legislation The U.S. Healthcare System s Cascade of Decision Side-effects C Fragmentation of care processes. Slips Lapses Mistakes... Cost Cutting Focus on Efficiency B Understaffing Time Pressure Fatigue Adverse Event A Clinical Space

Payments D Tort Law Legislation Judith s Story C New facility planned Cost cutting Focus on efficiency Normalized risk; unsafe behavior B Slips Lapses Mistakes... Time pressure, nominal workflow interrupted, unworkable procedure, inadequate # scanners.. Heightened potential for an adverse event Clinical Space A

Organizational Learning, Forgetting and The Functioning of Frontline Units Over Time Reliability Bankruptcy Latent Conditions Balance Latent Conditions Latent Conditions Adverse Outcome Efficiency Adapted from Managing the Risk of Organizational Accidents, J. Reason, 1997

Dampening the Accident See-Saw Sensitive Surveillance, CSE Investigation, and Corrective Action Reliability Bankruptcy Latent Conditions Balance Latent Conditions Latent Conditions Adverse Outcome Efficiency Adapted from Managing the Risk of Organizational Accidents, J. Reason, 1997

A Safety Management System Continual Surveillance: Detection, Identification, Corrective Response, Monitoring for Effect Changes Accelerated in clinical resources, tasks, Org. Response processes, tools Correction Goal conflicts, Constraints Adaptations, Workarounds, Normalized risk.. Near misses Injury or Death Proactive feedback loops Reactive Feedback Loops Early Identification and Management of Emergent Risk and Hazard in Clinical Space 1. Detection via Risk Triggers, Team Debriefing and Feedback, Safety Reports 2. Clinically situated investigation using the socio technical system lens (CSE methods) 3. Development of corrective action using investigative findings 4. Monitoring for intended and unintended effects 5. Ongoing surveillance, problem detection, and rapid cycle improvement

The system of interest for the improvement of patient safety is defined not by the business affiliations of providers, but by patient pathways within and among provider facilities, and by the information exchange that attends that patients care.

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