Download - Healthcare Safety
Healthcare SafetyAn Aviation Perspective
Michael Appel, M.D.30th International System Safety ConferenceAugust 7, 2012 Atlanta, GA
primumnon
nocere
Patient Safety It’s a DECISION we make
Patient Safety It’s a DECISION we make
“Safety” can best be defined as:
a) Eliminating harmb) Eliminating blamec) Being very carefuld) Investigating all errorse) Managing risk
CURRENT FINANCIAL INCENTIVES
DEFECTS
Toyota absorbs the cost of defects Healthcare MARKS UP and SELLS the defects
to the consumer In the future, the healthcare industry will have to absorb the costs of defects
SAFETY DECISIONS
WHO does the work? HOW we do the work? WHAT level of risk is acceptable?
1
Risk=Safety
Risk =
(available mitigating resources)
(likelihood of failure)x (magnitude of harm)x (acceptable harm rate)
1
Risk=Safety
RESOURCES ODDSx CONSEQUENCESx INVISIBILITY
=Safety
RESOURCES ODDSx CONSEQUENCES INVISIBILITY
=Safety
x
x VISIBILITY
Barriers to “RESOURCES”
Shrinking margins / financial distress Impending “reform” Short-term ROI Industry-wide lack of SYSTEMS approach
Barriers to “VISIBILITY” Brilliant physician Looming lawyers NO safety expertise Good outcome = “safety” Industry-wide lack of SYSTEMS approach
[email protected](678) 521-2418 cell