medical data recorder
TRANSCRIPT
Observatie in de OK
Martijn Kriens @martijnkriens, [email protected]
The old operating theatre, London
Martijn Kriens Medical Data Recorder
Research
Quality Assurance
Pilot
@martijnkriens, [email protected]
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
200420082012
Surgery is responsible for 60% of all Avoidable Errors (22.500)
Monitor Zorggerelateerde Schade 2008, NIVEL
Direct costs are > 125M euro per year
Systemic learningI am always ready to learn although I do not always like to be taught
Winston Churchill
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
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 ofprocesses
Plan the proces - checklists, …
Do according to agreed processes
Check expected outcomes with
reality
Act on deviations - analise and adapt
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/
Antic
ipat
ion
Cont
aim
ent
• 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
FailureSucces
? ? ?
• Collective memory• Shared stories
• Evidence based processes• organizational quality
• Team focus• Hierarchy
• An error does not imply guilt
© Medical Data Recorder
Less
ons
for s
urge
ry