The Human Factor : Teamwork and Communication in Patient Safety

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The Human Factor Teamwork and Communication in
Patient Safety

• Michael Leonard, MD
• April 14, 2004
• Dearborn, Michigan

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Our Conversation

• Why communication is the heart of the matter
• The limits of human performance
• Lessons from high reliability
• Human Factors Skills Briefings Time Outs,
  Pauses Assertion Its a hierarchical world
  Situational Awareness Debriefing

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A System Error
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Drawing the Bright Line
Malicious Substance Use Violation of Rules
Repeat Events Competency
remediate
NO RULE Substitution Test
Safe Harbor Systems Approach
Reason, J.
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Why Communication ?

• The overwhelming majority of untoward events
  involve communication failure
• Somebody knows theres a problem but cant get
  everyone in the same movie
• The clinical environment has evolved beyond the
  limitations of individual human performance

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Reoccurring Organizational Systems Problems

• Communication
• Shift reports, sign outs and hand-offs
• Inadequate, inaccurate information
• Task fixation, task overload
• Assertion, escalation of communication
• Supervision, leadership

MMI Company data of 250 hospitals over 10 years
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Our Error Model Today

• Trained to be perfect - knowledge and competence
  are equated with the absence of error.
• Medical culture rewards perfection and frowns
  upon error.
• Individual agency - fix the person and the
  problem goes away.

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Error is Inevitable Because of Human Limitations

• Limited memory capacity 5 pieces of information
  in short term memory
• Negative effects of stress error rates
• Tunnel vision
• Negative influence of fatigue and other
  physiological factors
• Limited ability to multitask cell phones and
  driving
• Flawed judgment

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Anesthesia Error

• Human error accounts for 80
• Failure to perform normal check
• Lack of proficiency with equipment
• Lack of vigilance, distraction
• Haste
• Lack of experience with technique

Cooper et al, Anesthesiology, 1984
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JCAHO Sentinel Events

• Communication breakdowns remain the primary root
  cause of more than 60 of the 2034 sentinel
  events analyzed.
• The majority of sentinel events (75) resulted in
  a patient death.
• Suicide (16.1)
• Operative/postop complications (12.4)
• Wrong-site surgery (11.8)
• Medication errors (11.5)

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JCAHO Patient Safety Goals

• Read-backs on verbal orders
• Identify patient from 2 sources
• Verification of correct patient, correct site,
  correct procedure
• Briefings before procedures, operations
• Infusion pumps / monitor alarms
• Nosocomial Infections

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What Does America Think ?

• 42 of Americans have had personal experience
  with a medical error
• In 38 of those cases, the system was unresponsive

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What Do Patients Want After a Medical Error ?

• An honest explanation.
• An apology.
• A guarantee it wont happen to anyone else.
• Lexington VA experience.

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MD RN Different Communication Styles

• Nurses are trained to be narrative and
  descriptive
• Physicians are trained to be problem solvers
  what do you want me to do just give me the
  headlines
• Complicating factors gender, national culture,
  the pecking order, prior relationship
• Perceptions of teamwork depend on your point of
  view

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ICU Teamwork Discrepant RatingsAveraged across
32 ICUs Dr. Bryan Sexton
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Quality of Teamwork across 25 organizationsDiffe
rences between Physicians Nurses
Quality of Teamwork Scale (1very low to 5very
high)
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Teamwork Climate Annual Nurse Turnover
 
reporting positive teamwork climate
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SYSTEMS OF CARE

• 80 medical error is system derived
• 95 mistakes the good guys
• Get the bad apples no !
• Fix hard to do the wrong thing, predictability

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United Portland Human Factors Surface
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Crew Resource Management

• Focus on teamwork,communication, flattening
  hierarchy, managing error, situational awareness,
  decision making
• Non-punitive reporting of near misses, 500,00
  reports over 15 years
• Very open culture with regard to error and safety

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High Reliability

• Preoccupation with Failure
• Refusal to Simplify
• Commitment to Resilience
• Deference to Expertise
• Sensitivity to Operations

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High Reliability Units

• Safety first is the hallmark of the culture
• Team contribution is valued
• Communication is structured and rewarded
• MD comes when called by RN
• LD is viewed as potentially dangerous to guard
  against complacency
• Fetal and maternal wellness are defined
• Evidence-based protocols are utilized
• Emergencies are rehearsed

Knox, Simpson, JHRM, Spring 99
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What Lessons Can We Learn From Industry ?
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Industry LeadersOperationally excellentConsisten
tly profitableExcellent workforce morale

• Toyota
• Southwest Airlines
• Alcoa

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3 Conditions of Habitual Excellence

• A fundamental, non-negotiable respect for every
  employee every day by everyone they meet
• The tools and flexibility to do the job
• The work is recognized and acknowledged

Paul ONeill NPSF 2003
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• Is Technology the Answer ?

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HUMAN FACTORS

• Briefings
• Appropriate Assertion
• Situational Awareness
• Debriefing
• Common Mental model

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Setting the Stage

• Vascular surgeon doing new, complicated procedure
  endovascular aortic stent - in CV lab
• I dont have any pride invested here. I just
  want to get this right, so if you think of
  anything helpful or see me doing anything wrong,
  please let me know.

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I know the names of all the personnel that I
worked with during my last shift
 
of respondents who agreed
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Briefings - Key Elements Checksheet

• Got the persons attention
• Made eye contact, faced the person
• Introduced self
• Used persons name familiarity is key !
• Asked knowable information
• Explicitly asked for input
• Provided information
• Talked about next steps
• Encouraged ongoing monitoring and cross-checking

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Situational Briefing Model

• S-B-A-R
• Situation
• Background
• Assessment
• Recommendation

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Situational Brief Example

• Situation Dr. Jones, Im Paul, the respiratory
  therapist. In my HF training, I was told to get
  help if I am worried about a patient. Theres
  someone downstairs whos in serious respiratory
  distress.
• Background He has severe COPD, has been going
  downhill, and is now acutely worse..

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• Assessment His breath sounds are way down on the
  right side I think he has a pneumothorax and
  needs a chest tube pronto before he stops
  breathing.
• Recommendation Id like you to come with me now
  and see himI really need your helpthis guys in
  real trouble.

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Assertion - What is it?

• Individuals speak up, and state their
  information with appropriate persistence until
  there is a clear resolution.

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Assertion

• Model to guide andimprove assertion inthe
  interest of patient safety

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Why is Assertion So Hard ?

• Hierarchy / power distance
• Lack of common mental model
• Dont want to look stupid
• Not sure Im right
• Other?

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Situational Awareness Recognizing Adverse Events
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Expert Decision Making

• Expert pattern matching against large mental
  library, quick, accurate if confirm correct
  answer
• Novice library is empty slow, error prone
  process
• Certain Diagnoses are Favored- Frequent, Recent,
  Serious
• Heuristics

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Red Flags Loss of Situational Awareness

• Ambiguity
• Reduced/poor communication
• Confusion
• Trying something new under pressure
• Deviating from established norms
• Verbal violence
• Doesnt feel right
• Fixation
• Boredom
• Task saturation
• Being rushed / behind schedule

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Debriefing

• An opportunity for individual, team and
  organizational learning
• The more specific, the better
• What did we do well?
• What did we learn?
• What would we do differently next time ?
• Key element in HBR study Bohmer, Edmondson and
  Pisano

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• The quality of the debrief is closely linked to
  the quality of the initial briefing