unit-based safety - ensuring high reliability best practices
TRANSCRIPT
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Unit-based Safety
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Username and Password
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What is an HRO?
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High Risk, High Consequence Organizations
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What About Healthcare?
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1999 Institute of Medicine report:
“To Err is Human”
44,000 to 98,000 preventable deaths
annually
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Are we safer 20+ years later?
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Caution: Hospital Ahead
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Fair and Just• Diverse, Inclusive, and Equitable• Seeks Learning over Blame• Accountable
Open and Transparent• Safe Event Reporting and Review
Dynamic Learning• Proactive • Innovative• Shared
Resilience• Organizational & Individual
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Bringing the Equity Lens to Safety
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Inequities Cause Harm
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Why Things Go WrongSystems Humans
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Personal• Fatigue
• Stress
• Health
• Competing Goals
• Values
Professional• EPIC
• Environment
• Culture
• Competing Goals
• Values
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Daniel Kahneman
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Our two brains
• Unconscious reasoning
• Automatic / FAST
• Conscious reasoning
• Effortful / SLOW
System 1 System 2
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The Awareness Test
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Dagen H – “H-Day”
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Error vs Choice
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An experienced surgeon sees a new piece of equipment at a conference.Back at the hospital, a sales rep. persuades him to use the equipment for a procedure. Having never used the equipment before he accidentally punctures the patient’s bowel. The surgeon repairs the bowel and the patient recovers fully.
The OR has a policy that says new equipment will be officially approved and training conducted prior to its use.
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An experienced surgeon sees a new piece of equipment at a conference.Back at the hospital, a sales rep. persuades him to use the equipment for a procedure. Having never used the equipment before, he accidentally punctures the patient’s bowel. The surgeon repairs the bowel but the patient later develops a life-threatening infection as a result of the accidental puncture.
The OR has a policy that says new equipment will be officially approved and training conducted prior to its use.
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Question:
Should the Surgeon be disciplined?
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Discipline Surgeon?
Review Group Grp 1 (No Harm) Grp 2 (Harm) Managers 0% 50%Physicians 0% 45%
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Outcome / severity bias
When leadership allows the severity of the outcome…
…. to drive its response to an event
WHAT IS IT?
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Outcome / severity bias
“No Harm, No Foul”
TRAGIC EFFECTS
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Errors are caused by “normal” rather than “abnormal” behavior.
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Lucian Leape
“The single greatest impediment to error prevention is that we punish
people for making mistakes.”
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“Man was made at the end of the week's work, when God was tired.”
- Mark Twain
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You Have Just Two Choices:
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How often do we feel safedoing risky
things?
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Our Internal “Risk Monitor”
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Would you choose to drive around?
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Another At-Risk Behavior (choice)
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The Swiss Cheese Model (James Reason)
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Coaching and behavior modification
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“Let’s keep this shot just a little left.”
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Changing Behaviors
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Good System DesignError Proofing
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User Experience, Design
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Learning Systems
REACTIVE− Looks Back
− Local Learning
− Error Focused
− Outcome Bias
− Address the Human
PROACTIVE− Looks Forward
− Shared Learning
− Risk Focused
− Outcome Blind
− Address the System
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Good System Design
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