Transcript Dia 1 - TU Delft

Awareness of Quality of Care
• 56 countries, 281 million operations,
1 operation for every 25 human being alive per year.
• Major complications: 3 – 16%
• Death rate:
0.4 to 0.8%
• Assuming 3% adverse events and 0.5 death rate:
7 million suffered adverse event.
• 1 million die during or after surgery.
• More than halve of the events are known to be
preventable.
• A major cause of death and disability worldwide.
Onbedoelde schade in Nederlandse
ziekenhuizen
• In 2004 42000 patients died in hospitals
• 3% of admissions
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5.7% adverse events
4.1% deaths related to adverse events
Estimated deaths 1735
Life expectations of these patients were in one-third
1 – 5 years, in 18% more than 5 years
• 54% of adverse events are surgery related
EMGO Instituut and NIVEL, 2007
www.nivel.nl
“Good people are set up to fail in bad systems.
Let’s figure out how to keep everyone safe”
• We are in a strange place. Everyone knows
there is a problem, but we don’t know how to fix
it.
Sir Ian Kennedy,
Conference Everybody’s Business,
2006
Why high-risk processes in the OR
are prone to process failure?
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variable input
complicity
inconsistency
tight coupling
human interaction
time pressure
hierarchical culture
Factors responsible for error
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 Workload
 Inadequate knowledge or experience
Poor human factor design
 Inadequate supervision or instruction
Stressfull environment
 Mental fatique or boredom
Rapid change
Conflicting goals influencing process in the OR
Event
litigation
Achieve optimal
patient’s safety
relation to
other
specialities
Competition
(market
working)
Limit costs
New
technology
maximized
diagnosis
Increase
production
Shift to a day
surgery
New
procedures/technique
(NOTES)
System behaviour - adverse event trajectory
Fault quality control
Communication
Staff training
Resources
Facility
Situational factors
Unlucky
circumstances
Faulty action
Latent failure Active failure
Care provider
Technical staff
Information system
Management
Safety barrier
absolute or relative
Adverse event
Pathways to adverse event analysis, DEB and MTO.
Perform team
Select process
DEB
(proactive)
Evaluate system
effect of disturbance
Map process
Hypothetic
disturbance
Validate
hypothesis
Search for latent
failures and barrier
to be adjusted
Identify options
or insufficient
barriers
Implement error
containment actions
Develop preventive
actions
Safety
improvement
Identify latent
failures
View event View cause Barrier
mapping
analysis analysis
MTO
(reactive)
Map event
Identify situational
factors
Investigation
and
……………
MTO = Man Technology Organisation = HEPS =
Human performce Enhancement System
Close analysis
DEP = Disturbance Effect Barrier
Exploration of gaps
The role of gaps in the continuity of care processes and
patient’s safety – challenging but promising
• Catalogue gaps and map them
• Find out how experts detect, anticipate and bridge gaps
• How gaps are created by organisational and institutional
changes
Outcome of explorations can provide a coherent useful
view on patients safety and be appleid to identify future
safety problems, anticipate the impact of change and
measure the progress.*
* R.I. Cook (2008)
Stakeholders with potentially conflicting goals
Event reporting system does it work?
Hospital
management
Media
Individual care
provider
Insurers
Staff of
department
Staff
involved
Patient’s
family
Advocacy
groups
Others?
Patient
Attorneys
Supporting technical
staff
Reducing errors through work system
improvements
Standardised
Simplify
process
Reduced
Reliance
on memory
Design for
errors
Adjust work
schedules
Optimize information
access and quality
Optimize
the environment
Improve
communication
Adequate
safety training
Right people
for the job
Improved
Work
System
CIRCULATING
NURSE
ANESTHESIOLO
GIST ASSISTENT
ANESTHESIOLO
GISTS
SURGICAL
NURSES
SURGEONS
SUPPORT
SERVICES
PATIENT
Other
specialists
Team dimensions and their
interrelationship.
Perform procedure as planned
and manage workload
Operational
team actions
Communicate
with team
Problem solving
Team structure
and climate
Team work skills
And expertise
Fundamental
requirements
Creating common mental model for
surgical team in operating theatre
• getting everyone on stage in the same play
safe environment (feel free to speak up, if any safety concerns)
• getting everyone on stage in the same play, and no
plot changes
OR-teams should be unitairy and cohesive in order to achieve high-level of
performance
SBAR
Approaches and behaviour for improvement of communication
• Situation
– What is going on?
• Background
– What is clinical
background/context?
– What I think the
problem is?
– What would I do to
correct it?
• Assessment
• Recommendation
CUS
Critical language approach.
“I am concerned”
“I am uncomfortable”
“This is unsafe”
“I am scared”
Safe performance of task
How human solve problems
Main
rules
Side rules
Exception of rules
Knowledge from experience:
Scripts/schematas
Problem solving - Rasmussen
•Skill-based
•Rule-based
•Knowledge-based
•Simulation
Standardised task
Novel situation with some likelihood
Entirely new situation
apprenticeship
Experience
Equipment  Time out  Black box  Debriefing