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Challenges to Learning: Patient Safety Events in Complex systems Patient Safety Event Learning Seminar Deer Lodge Centre, Winnipeg, MB November 2, 2010

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Challenges to Learning:

Patient Safety Events inComplex systems

Patient Safety Event Learning Seminar

Deer Lodge Centre, Winnipeg, MB

November 2, 2010

Challenges to Learning: (forget about complex systems)

The usual suspects:

– Fear of consequences

– Fear of the law

– Lack of controls (as in cybernetics)

– Messy mental models

– Learning anaphylaxis

Page 3: Challenges to Learning: Patient Safety Events in Complex systems Patient Safety Event Learning Seminar Deer Lodge Centre, Winnipeg, MB November 2, 2010

Challenges to learning: Fear of consequences

Fear of consequences

– From the facility – where is the Just and Trusting Culture policy?

– From the department – where is the inter-disciplinary support and commitment to learning?

– From the unit – what will and won’t be used in performance management assessments? (back to the J+T Culture thing)

– From colleagues – how we do things around here?

Page 4: Challenges to Learning: Patient Safety Events in Complex systems Patient Safety Event Learning Seminar Deer Lodge Centre, Winnipeg, MB November 2, 2010

Challenges to learning: Fear of the law

Fear of the law:

– “Blueprint” for litigation

– PHIA-noia

– FIPAA-bility

– Bogeyman of the criminal charges

– Do you like to gamble? (1/13 versus 1/160,000)

Page 5: Challenges to Learning: Patient Safety Events in Complex systems Patient Safety Event Learning Seminar Deer Lodge Centre, Winnipeg, MB November 2, 2010

Challenges to learning: Lack of controls

Lack of controls (cybernetics gone wild):

– Feedback to staff – why bother reporting?

– Feedback to patients/families – why bother trusting?

– “Feed forward” to other units – why wash “dirty laundry”?

– “Feed forward” to anybody who is interested – the problem of the big bad internet?

Page 6: Challenges to Learning: Patient Safety Events in Complex systems Patient Safety Event Learning Seminar Deer Lodge Centre, Winnipeg, MB November 2, 2010

Challenges to learning: Messy mental models

Messy mental models:

• Variation of “if it walks like a duck and looks like a duck…”

• Using linear (or occasionally epidemiological) models to understand the events

• Searching for certainty – “We can’t be sure that the infection led to the patient’s demise, so we can’t consider this a critical incident….”

• Homage to Rene Descartes

Page 7: Challenges to Learning: Patient Safety Events in Complex systems Patient Safety Event Learning Seminar Deer Lodge Centre, Winnipeg, MB November 2, 2010

Challenges to learning: Learning anaphylaxis

Learning anaphylaxis:

– Is the facility a learning organization?

– Is the department a learning department?

– Is the unity a learning unit?

– Three cheers for today’s session!!

Page 8: Challenges to Learning: Patient Safety Events in Complex systems Patient Safety Event Learning Seminar Deer Lodge Centre, Winnipeg, MB November 2, 2010

Challenges to learning: In a complex system

Healthcare is a complex system:

– Probably a hybrid compared to other complex systems

– Open versus closed system

– Complex adaptive system (NDS) – dynamic nature

– Complex socio-technical (or T-S) system – love the technical stuff

– Basically a mysterious beast – the case of the dog that didn’t bark in the night…

Page 9: Challenges to Learning: Patient Safety Events in Complex systems Patient Safety Event Learning Seminar Deer Lodge Centre, Winnipeg, MB November 2, 2010

Challenges to learning: In a complex system

Some surprising elements:

– Nonlinear causation

– Emergent versus resultant properties

– The importance of context – holistic approach

– The system has a history

– Relationships between components more important than the components themselves

Page 10: Challenges to Learning: Patient Safety Events in Complex systems Patient Safety Event Learning Seminar Deer Lodge Centre, Winnipeg, MB November 2, 2010

Challenges to learning: In a complex system

All of this requires:

– Different ways of thinking to recognize learning opportunities

– Different ways of reviewing/investigating events to promote understanding

– Different ways of talking about events to promote active and applicable learning

– (Sounds like hard work….it isn’t)

Page 11: Challenges to Learning: Patient Safety Events in Complex systems Patient Safety Event Learning Seminar Deer Lodge Centre, Winnipeg, MB November 2, 2010

Challenges to learning: In a complex system

Questions?

Contact info:

Rob RobsonHealthcare system Safety Advisor

[email protected] 519-846-28721-877-405-9313

mailto:[email protected]

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