I MAKE ERRORS….YOU WILL TOO!

Prepared by:Gord Vail, M.Sc., MD

Chief of Staff, Hotel-Dieu Grace HospitalWindsor ON

I’M A FAILURE….YOU CAN BE TOO!

DISCLOSURES

Advisory Boards● Hoffman-LaRoche● Bayer

Sponsored Speaker● Hoffman-LaRoche● Bayer● Sanofi-Aventis

Educational Grants for HDGH Grand Rounds● Leo Pharma● Sanofi-Aventis

ERRORS AT WORK

• Categories of errors Examples

• Change management Why it’s difficult

• Errors in Administrative Projects

QUOTE

“A failure is a man who has blundered but is not able to cash in on the experience.”

Elbert Hubbard (1856-1915) American author & philosopher

GOD SAVE THE THE QUEEN

QUESTION

What did the last slide say?

ATTRIBUTION ERROR

● Or pattern recognition error● Why did you see something different?● What conditions occur at work that could make such an

error occur?○ Labeling

○ Location ○ Same patient, day after day…

- Chest pain in the ED ○ Old charts● Our PA example

THE TYPICAL INNER-CITY ED PATIENT…

Chronic pain/alcoholic/homeless patient in the hallway

Our PA sees them (unusual)

Finds abnormalities

If one of the attendings with their past experience saw them???

AN EXAMPLE CLOSE TO HOME…

General surgeon gets a referral• ?Breast cancer• U/S ordered by FMD for ?Breast cancer• U/S report RFR included with referral: ?Breast cancer• U/S guided biopsy for ?Breast cancer• Pathology report RFR: ?Breast cancer

What do you think happened?• Actual diagnosis on pathology – NOT breast cancer

CONFIRMATION BIAS

We try to find data that will support our hypothesis What gets written on a chart is your interpretation of the

interaction

What do you ignore in your practice? “Typical” chest pain Usual IVDA patient Psychiatry patients with medical illnesses

How can you avoid this? Truly listen…to the patient and that voice in your head!

IMPLEMENTING CHANGE

My story • HDGH LEAN Initiatives• Dr. David Ng & I• Leadership• Computerization of the ED

What did it show?

What learnings came out?

WHICH PROJECT SUCCEEDED?

WHY IS CHANGE IMPORTANT?

“The major problem with planning is that plans are virtually always wrong.” Brown & Eisenhardt 1998

The Emergency department is a fairly stable environment• 1 ICU admit/d, 4 medical, 4 hospitalist, 12% admission rate

It’s the long-term issues facing a hospital that change:• Funding• Technology • Care models

I’M A FAILURE… YOU’RE GOING TO FAIL…

Management projects failure rate = 80%• We have to learn from failure

Culture of Blame• If not supportive, who’s going to lead a project doomed to fail?• Why try to lead?• How can you change it?• Do you really think everyone at your hospital wants you & PIP

or P4R to succeed?

These are the important questions that need to be asked!

RESEARCH COMPONENT

• Everyone’s involved in before/after scenarios

• Not the most rigorous but still useful• Will help others

Our experience with communication

My colleague/friend in telestroke medicine

Always need proof (and more proof!) that something works

Ideas for improvement Not everything intuitively correct

is proven to be so…

Target patterns of ten shots fired by two riflemen. A’s pattern exhibits noconstant error, but rather large variable errors. B’s pattern shows a large

constant error, but small errors. (from Chapanis, 1951).

THREE TYPES OF HUMAN ERRORS1. Skill Based

Slips or lapses, i.e. forgetting your keys in the a.m.!

2. Rule Based Brain processes

Go back into your experience and find correct response, for example a differential diagnosis for SOB

3. Knowledge Based Lack of knowledge

Shouldn’t reach the patient Barriers such as co-signing for clerks/residents

James Reason’s Swiss Cheese model from 1990 Puts up barriers to prevent the error from propagating

STAR technique used to assist with prevention Stop, think, act, review

THE SWISS CHEESE MODEL

The Swiss cheese model of how defenses, barriers, and safeguards may be penetrated by an accident trajectory.

HIERARCHAL ERRORS

Usual example to start with is pilots• Who flies?

See any relation to medicine?• Who tells on an attending when you’re in training?

Cultural change• Errors are talked about• Legislated in Canada about when & how to disclose an error

Can work for you• Examples from the leaders filter down• An example from HDGH is Hand washing!

PERSON OR SYSTEM APPROACH?

Person focuses on the individual• Forgetfulness, inattention or moral weakness

System looks at conditions around person’s work• Build defenses to avert or mitigate an error’s effects

But, isn’t blaming an individual easier & more satisfying??• Less institutional responsibility• Less time consuming• No work to fix; just eliminate the individual

SUMMARY

Leaders in the crowd Be kind! Acknowledge your failures and errors; Powerful to those you

work with.

Think of the big picture One person made the error that’s going to allow you to rework

the system that led to the error; Difficult to do but necessary

Keep trying things Hit that 20% goal!

THANK YOU!

QUESTIONS OR COMMENTS?