Obstetrics and Anaesthesiology Amarin Narkwichean MD PhD Clinical Lead Team CLT Department of Obstetrics and Gynaecology Faculty of Medicine Srinakharinwirot University Learning objective ID: 649387
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Slide1
Patient Safety for Medics: Obstetrics and Anaesthesiology
Amarin Narkwichean, MD. PhD.
Clinical Lead Team (CLT)
Department of Obstetrics and
Gynaecology
Faculty of Medicine,
Srinakharinwirot
UniversitySlide2
Learning objective
Understand
the discipline of patient
safety
Understand human factors and its relationship to patient safety
Understand how systems thinking can improve health care and minimize patient adverse events
Understand the nature of error and how health care can learn from error to improve patient safety
Know how to apply risk management principles by identifying, assessing and reporting hazards and potential risks in the workplace
Understand the importance of teamwork in health
care and learn how to be an effective team player as a medical student Slide3
1. Patient Safety
เป็น
สาขาวิชาในภาคบริการสุขภาพ
ที่นำวิธีการทางวิทยาศาสตร์และการจัดการด้าน
ความ
ปลอดภัยมา
ใช้
เพื่อให้
ได้ระบบการให้บริการ
สุขภาพทีเชื่อถือ
ได้
เป็น
ส่วน
หนึ่ง
ของระบบบริการสุขภาพ
ที่ลดอุบัติการณ์ ลดผลกระทบ
เพิ่ม
การ
กลับสู่สภาพเดิม
(maximizes recovery)
จากเหตุการณ์ที่ไม่พึงประสงค์
(adverseevents) Slide4Slide5
Harm caused by health-care errors and system failures
E
xtent
of
adverse events
Categories
of adverse events
Economic
costs
Human
costsSlide6
Human factors definition
The
study of all the factors that make it easier to do the work in the right way
Apply
wherever humans work
Also
sometimes known as ergonomics
Topic
2: What
is human factors?Slide7
Human factors
Acknowledgement:
the universal nature of human fallibility
the inevitability of error
Assumption
that errors will occur
Design
things in the workplace to try to minimize the likelihood of error or its consequencesSlide8
Because the human brain is ….
very powerful
very flexible
good at finding shortcuts (fast)
good at filtering information
good at making sense of things
Sometimes though our brain
is “
too clever” …Slide9
Are the lines crooked or straight?
Optillusions.comSlide10
Look at the chartSay the colour of the word, not the word itself
Why is it hard?
Optillusions.comSlide11
The fact that we can misperceive
situations despite the best of
intentions is one of the main reasons
that our decisions and actions can
be flawed such that …
Making Clinical Judgment within a second
From various sources of input
Seems inevitably making errors!!! Slide12
Human factors experts
Design
improvements in the workplace and
the
equipment to fit human capabilities and
limitations
Make
it easier for the workers to get the work
done the right way
Decrease
the likelihood of errors occurring
T
he
design of tools
, machines
, systems, tasks, jobs, and environments for productive, safe, comfortable and effective human use.Slide13
Human factors
design
principles
Senses
- Vision - Hearing
Psychomotor
Hands
Input Devices
Buttons
Output
- Display - Sound
INTERFACE
US Department of Veteran affairs
Slide14
Avoidable confusion is everywhere…
US Department of Veteran affairs
Slide15
One definition of “human error” is “human nature”
Error is the
inevitable
downside
of having a brain!Slide16
What is an error?
T
he
failure of a planned action to achieve its intended outcome
A
deviation between what was actually done and what should have been done
Reason
A definition that may be easier to remember is:
“Doing the wrong thing when meaning to do the right thing.”Slide17
Note: violation
A deliberate
deviation from an accepted protocol or standard of care Slide18
Error and outcome
E
rror
and outcome are not inextricably linked:
Harm
can befall a patient in the form of a complication of care without an error having occurred
Many
errors occur that have no consequence for the patient as they are recognized before harm occurs
Harm/AEs
ErrorsSlide19
Health-care context is problematic
W
hen
errors occur in the workplace the consequences can be a problem for the patient
a situation that is relatively unique to health care
I
n
all other respects there is nothing unique about
“
medical
” errors they are no different from the human factors problems that exist in settings outside health careSlide20
Situations associated with an increased risk of error
Unfamiliarity
with the task*
Inexperience
*
Shortage
of time
Inadequate
checking
Poor
procedures
Poor
human equipment interface
Vincent
*
Especially if combined with lack of supervisionSlide21
Individual factors that predispose to error
Limited
memory capacity
Further
reduced by:
fatigue
stress
hunger
illness
language or cultural factors
hazardous attitudes
Slide22
Fatigue
24 hours of sleep deprivation has performance effects
~
blood alcohol content of 0.1%
Dawson –
Nature, 1997Slide23
Stress and performance
The relationship between stress and performance
Stress level
Area of “optimum” stress
Low stress Boredom
High stress Anxiety, panic
Performance level
Yerkes, R. M., & Dodson, J. D. (1908) The relation of strength of stimulus to rapidity of habit-formation.
Journal of Comparative Neurology and Psychology, 18
, 459-482Slide24
Don’t forget ….
If you’re
H ungry
A ngry
L ate
or
T ired …..
H
A
L
TSlide25
A performance-shaping factors “checklist”
I Illness
M Medication
prescription, alcohol & others
S Stress
A Alcohol
F Fatigue
E Emotion
Jensen, 1987Slide26
Apply human factors thinking to your work environment
Avoid reliance on memory
Make things
clearly visible
Review
and simplify processes
Standardize common processes and procedures
Routinely use checklists
Decrease the reliance on vigilanceSlide27
Health care is a
complex
system
I
ncreased chance of something going wrong!
Topic 3 : Understanding systems and the impact of complexity on patient careSlide28
Two schools of thought regarding iatrogenic injury
Traditional
or person approach
* the “old” culture
* “just try harder”
Systems
approach
* the “new look”
You may encounter a bit of both in your “journey”Slide29
Person approach
See
an errors as the product of carelessness
R
emedial
measures directed primarily at the
error-maker
Naming
Blaming
Shaming
R
etraining
Perspectives on errorSlide30
An individual failing?
Doesn’t work!
People
don’t intend to commit errors
only a very small minority of cases are deliberate violations
Won’t
solve the problem - it will make it worse Countermeasures
create a false sense of security
“we’ve ‘fixed’ the problem”
Clinicians
will hide errors
May
destroy many clinicians inadvertently
the second victimSlide31
Why investigate?
The
more we understand how and why these things occur, the more we can put checks in place to reduce recurrence
Strategies
might include:
Education
New
protocols
New
systemsSlide32
Multiple factors
usually involved
patient factors
provider factors
task factors
technology and tool factors
team factors
environmental factors
organizational factorsSlide33
Reason’s
“
Swiss cheese
”
model of accident causation
Some holes due
to active failures
Other holes due to
latent conditions
Successive layers of defences, barriers
and
safeguards
Hazards
Losses
System defencesSlide34
Swiss cheese model
Why do interns make prescribing errors? A qualitative study MJA 2008; 188 (2): 89-94
Ian
D
Coombes
, Danielle A
Stowasser
, Judith A
Coombes
and Charles
Mitchell; Adapted
from Reason’s model of accident causation
Failure
Organisation
influences
S
upervision
P
reconditions
Specific acts Slide35
Reason’s - Defences
VA NCPSSlide36
Characteristics of high reliability organizations (HROs)
Preoccupation
with failure
Commitment
to resilience
Sensitivity
to operations
A
culture of safetySlide37
Key principles from HRO theory
Maintain
a powerful and uniform culture of safety
Use
optimal structures and procedures
Provide
intensive and continuing training of individuals and teams
Conduct
thorough
organisational
learning and safety managementSlide38
The aircraft carrier:
T
he
prototypical HRO
Carriers achieve
nearly
failure-free record despite multiple hazards
GabaSlide39
Health care can learn
many lessons from HROs
Although health care is different from other industries (e.g.
people are not airplanes) we can learn:
from their successes:
What factors make them work so well?
from their failures:
How do disasters occur even in typically high reliability settings?Slide40
Incident monitoring
I
nvolves
collecting and
analysing
information about any events that could have harmed or did harm anyone in the organization
A
fundamental component of an organization’s ability to learn from error
Topic 4: Understanding and learning from errorSlide41
Removing error traps
A
primary function of an incident reporting system is to identify recurring problem areas
- known as
“
error traps
”
(
Reason)
Identifying and removing these traps is one of the main functions of error management
Error trapsSlide42
Modified from Cook, 1997
Hindsight Bias
Before the Incident
After the IncidentSlide43
Culture: a
workable definition (Reason)
Shared values (what is important) and
beliefs (how things work) that interact
with an organization’s structure and
control systems to produce behavioural
norms (the way we do things around here)
Safety cultureSlide44
Culture in the workplace
I
t
is hard to “change the world” as a junior doctor
but
…
Y
ou
can be on the look out for ways to improve the “system”
Y
ou can contribute to the culture in your work environmentSlide45
Incident reporting and monitoring strategies
Others
include:
A
nonymous
reporting
T
imely
feedback
O
pen acknowledgement of successes resulting from incident reportingReporting of near misses “Free lessons” can be learned
S
ystem
improvements can be instituted as a result of the investigation but at no “cost” to a patient
LarsonSlide46
Complaints
A
ssist
in maintaining standards
R
educe
the frequency of litigation
H
elp
maintain trust in the profession
Encourage self-assessmentProtect the publicSlide47
Root cause analysis
A
rigorous, confidential approach to answering
:
What happened?
Why did it happen?
What are we going to do to prevent it from happening again?
How will we know that our actions improved
patient safety?
Established by the US Department of
Veterans
Affairs
National
Center
for Patient
Safety
http://www.va.gov/NCPS/curriculum/RCA/index.htmlSlide48
RCA model
F
ocuses
on prevention, not blame or punishment
F
ocuses
on system level vulnerabilities rather than individual performance
C
ommunication - Environment/equipment
T
raining (Experience) - Rules/policies/procedures/managementFatigue/scheduling - BarriersSlide49
Sentinel events
unexpected occurrence involving death or serious physical or psychological injury and includes any process variation for which a recurrence would carry a significant chance of serious adverse outcome
JCAHO, 1999 Slide50
What is a team?
A
team is a
group of two or more individuals who:
i
nteract dynamically
h
ave a common goal/mission
h
ave been assigned specific tasks
p
ossess speciali
z
ed and complementary skills
Topic 5: Being an effective team playerSlide51
What makes for a
successful
team?
E
ffective teams possess the following features:
a
common purpose
m
easurable goals
e
ffective leadership and conflict resolution
g
ood communication
g
ood cohesion and mutual respect
s
ituation monitoring
s
elf
-
monitoring
f
lexibilitySlide52
Communication
A number of techniques have been developed to promote communication in health care
includ
ing
:
SBAR
(
Situation
,
Background
,
Assessment
, Recommendation)
c
all-out
c
heck-
b
ack
h
andover
/
h
andoffSlide53
Resolving disagreement
and
conflict
A number of techniques have been developed to help all members of a team speak out
includ
ing
:
T
he
two challenge rule
CUS
(
I
am
C
oncerned, I am
U
ncomfortable and this is a
S
afety
Issue)
DESC
script
(
D
escribe,
E
xpress,
S
pecify,
C
onsequence) Slide54
Example of team mutual support
https://youtu.be/yr6rxdqLy2MSlide55
Barriers to teamwork
c
hanging roles
m
edical hierarchies
i
ndividualistic nature of medicine
i
nstability nature of teamsSlide56
Incidents in other industries
Failures in the following team behaviours have been identified as being responsible for accidents in other industries:
r
oles not being clearly defined
l
ack of explicit coordination
m
iscommunication/communicationSlide57
Performance requirements…
Practical tips medical students can start practising now to improve teamwork include:
always introducing yourself to the team
reading back/closing the communication loop
stating the obvious to avoid assumptions
asking questions, checking and clarifying
delegating tasks to people not to the air
clarifyng your role
using objective (not subjective) languageSlide58
Performance requirements…
Practical tips medical students can start practising now to improve teamwork include:
learning and using people’s names
being assertive when required
if something doesn’t make sense, finding out the other person’s perspective
doing a team briefing before undertaking a team activity and a debriefing afterwards
when conflict occurs, concentrating on “what” is right for the patient, not “who” is rightSlide59
Performance requirements
know how to report known risks or hazards in the workplace
keep accurate and complete medical records
self-assess to reduce the risk of errors caused by inadequate knowledge and skills
participate in meetings that discuss risk management and patient safety
respond appropriately to patients and families after an adverse event
respond appropriately to complaints Slide60Slide61Slide62Slide63
Group task: “Innovation Framework in Patient Safety”
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ปรึกษากับอาจารย์ประจำกลุ่ม เลือกเรื่องปัญหา Patient Safety ที่ต้องการศึกษา 1 เรื่อง นำเสนอผลการศึกษา ในสัปดาห์ที่ 9 ก่อน สอบลงกอง เป็น
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หัวข้อ: (
Related to SIMPLE)
ที่มา
:
(เหตุผลคร่าว ๆ ที่เป็นสาเหตุให้เลือกหัวข้อนี้
)
Recommendation
Current/Actual Practice
Desire Practice
Action
-Evidence based medicine
-Guideline (National/ International)
-Surveys
-Interview
-Direct observation
-Medical Review
CPG, CNPG (and actual practice)
Show evidences of actual practice : VDO clip, images,
Questionaire
, etc
.
Aimed mission and objective
Prioritisation
on what can be done in our hospital context
Severity of problems
Time
Budget
Limitations
Plan
Trial
(Analysis) or (Planned analysis – indices)
Gap Analysis