Quality Patient Safety Lessons from other Industries - PowerPoint PPT Presentation

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Quality Patient Safety Lessons from other Industries

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Title: Quality Patient Safety Lessons from other Industries


1
Quality Patient Safety Lessons from other
Industries
Quality Patient Safety Lessons Learned from
other Industries
2
Or making others best practices yours!
Quality Patient Safety Lessons Learned from
other Industries
3
Dr. Ken Green Commander, US Navy US Navy Bureau
of Medicine and Surgery 202-762-3032 Kenneth.green
2_at_med.navy.mil
Quality Patient Safety Lessons Learned from
other Industries
4
  • Personal background
  • Commander, United States Navy
  • Current assignment as Senior Healthcare Analyst,
    Clinical Support Division of Medical Operations
    at the Navys Bureau of Medicine and Surgery
  • Training Education
  • Aviation Safety, Anesthesiology, Dentistry and
    Bioengineering
  • Navy career for 23 years included 10 years as an
    Aerospace Physiologist and Aeromedical Safety
    Officer
  • Human Factor Analysis of (US Navy) Aircraft
    Mishaps
  • Aircrew Coordination Instructor for
  • Fighter Aircraft Aircrew / Helicopter Aircrews
  • Founded CounteRisk Technologies, Inc. (January
    2000)
  • Using aviation safety principles to train any
    team or group be it in aviation, medicine or
    business, in communication, decision making and
    mishap prevention.

Quality Patient Safety Lessons Learned from
other Industries
5
Disclaimer
Dr. Green is not receiving any funding,
compensation or special interest considerations
for his discussion on any products or procedures
mentioned during the course of this program. Any
apparent endorsement of said products are based
on his own opinions and not those of the United
States Navy.
Quality Patient Safety Lessons Learned from
other Industries
6
In Real Estate the mantra is location location
location
Quality Patient Safety Lessons Learned from
other Industries
7
For Teams, its Communication Communication
Communication!
Quality Patient Safety Lessons Learned from
other Industries
8
Why clear and accurate communication is so
important
Quality Patient Safety Lessons Learned from
other Industries
9
A panda walks into a café. He orders a sandwich,
eats it, then draws a gun and fires two shots in
the air.
Quality Patient Safety Lessons Learned from
other Industries
10
Why? asks the confused waiter, as the panda
makes towards the exit. The panda produces a
badly punctuated wildlife manual and tosses it
over his shoulder.Im a panda, he says, at the
door. Look it up.
Quality Patient Safety Lessons Learned from
other Industries
11
The waiter turns to the relevant entry, and sure
enough, finds an explanation.
Quality Patient Safety Lessons Learned from
other Industries
12
Panda. Large black-and-white bear-like mammal,
native to China. Eats, Shoots and Leaves.
From British bestseller, Eats, Shoots and
Leaves by Lynne Truss published by Gotham Books
Quality Patient Safety Lessons Learned from
other Industries
13
  • 2004 Quality Colloquium Talk
  • The OR as a Cockpit Human Factor and Aviations
    Lessons Learned for improving Crisis
    Communication and Decision Making in High Risk
    Critical Care Situations
  • My talk focused on the history of aviation CRM,
    and the 1999 IOM report and how aviation safety
    lessons learned could be easily adapted to
    improve medicines best practices to improve
    medical team communication and decision making in
    crisis situations.

Quality Patient Safety Lessons Learned from
other Industries
14
  • Aviations Lessons Learned
  • Pre-Flight Briefings
  • Post Flight Debriefs
  • Mishap Investigations
  • Analysis
  • Reporting
  • Includes Near Misses!

Quality Patient Safety Lessons Learned from
other Industries
15
  • Medicines Safety History
  • Human Factor Threats
  • Medical Mishap Events
  • Institute of Medicine Report
  • To Err is Human (1999)
  • Potentially 44,000 98,000 deaths from medical
    errors

Quality Patient Safety Lessons Learned from
other Industries
16
  • 2005 Quality Colloquium Talk
  • Team Training- Are you participating? the future
    of CRM and Team Training in Medicine- focus on
    why wouldnt you have a team training program.

Quality Patient Safety Lessons Learned from
other Industries
17
Military and civilian aviation programs have
achieved remarkable improvements in their mishap
rates over the last 25 years following the
introduction, and system wide implementation of
concerted efforts to target flight teams
awareness of human factor threats, communication
and decision making skills, and teamwork
improvement.
Quality Patient Safety Lessons Learned from
other Industries
18
Communication errors alone account for over 70
of all patient related medical errors in both
Navy and civilian medical practices.
Quality Patient Safety Lessons Learned from
other Industries
19
CRM programs, and the foundations upon which they
are based, have found their way into medical
literature and practice worldwide, both at the
critical care operating room, intensive care and
emergency department levels, as well as within
traditional patient care areas.
Quality Patient Safety Lessons Learned from
other Industries
20
Risks and Opportunities There are no risks to
deploying a program such as this. The benefits
of improved team performance, reduced errors and
positive successful and predictable patient
outcomes, far outweigh any possible financial
expenditure for training costs, including travel
of master trainers to MTFs to conduct training,
and the costs of lost provider time for those
participating in training sessions.
Quality Patient Safety Lessons Learned from
other Industries
21
  • How should we measure success
  • of these programs?
  • Reduction in Mishap Rates? (long term)
  • Increase in Reported Near Misses? (short term)
  • Decrease in staff conflict issues? (ongoing)

Quality Patient Safety Lessons Learned from
other Industries
22
  • 2006 Quality Colloquium
  • Conspicuously absent

Quality Patient Safety Lessons Learned from
other Industries
23
A Different Perspective about medical
teamsWhen a Doctor is the Patient
Quality Patient Safety Lessons Learned from
other Industries
24
  • Aviation Safety in Critical Care Medicine
  • Lessons Learned on my Back
  • One Dr.s Strangelove-
  • or how I learned to stop worrying and become
    part of my team

Quality Patient Safety Lessons Learned from
other Industries
25
  • At my last lecture, to a group of OR staff, a
    doctor in the audience commented Dr. Green you
    sure know a lot about neurocritical care, are you
    a neurocritical care specialist.
  • No, I answered, but I did stay in a Holiday Inn
    Express last night.

Quality Patient Safety Lessons Learned from
other Industries
26
COLLABORATION WITH MY DOCTOR
  • Brief recount of my experiences.
  • My surgeon became interested in the team training
    I did and had me lecture to his residents and
    fellow staff
  • He then asked me to collaborate with him on an
    exciting project he had begun to utilize some
    advanced telemedicine robotics to reach out and
    touch patients far away for improving neuro
    critical care.

Quality Patient Safety Lessons Learned from
other Industries
27
  • The remote presence robot, essentially a live
    action VTC developed by In Touch Health
    (www.intouchhealth.com ), enabled him and others
    to consult from afar on critical surgical
    interventions and other traumatic brain injury
    issues for wounded warriors injured in Iraq and
    Afghanastan.
  • He provided the neuro critical expertise while I
    am trying to bring the team communication issue
    of using devices such as this to the forefront of
    improved care and a new best practice.

Quality Patient Safety Lessons Learned from
other Industries
28
EXAMPLES
eexca
  • Trail of errors led to 3 wrong brain surgeries
  • Surgeons' ego at R.I. hospital may have led to
    carelessness, study says
  • PROVIDENCE, R.I. - One operation went awry after
    an experienced brain surgeon insisted to a nurse
    he knew what side of the head to operate on but
    got it wrong.
  • Another time, a doctor-in-training cut into the
    wrong side of a patient's head after skipping a
    pre-op checklist. In a third case, the chief
    resident started brain surgery in the wrong
    place, and the nurse didn't stop him.

Quality Patient Safety Lessons Learned from
other Industries
29
  • Nurses may be afraid to speak up
  • The mistakes at Rhode Island Hospital suggest
    that the precautions can still be thwarted by the
    human element ego and overconfidence on the
    part of surgeons, and timidity on the part of
    nurses too afraid to speak up when they see
    something about to go wrong.
  • "There's a big cultural issue in most operating
    rooms where there's a hierarchical culture there.
    A surgeon is used to being the captain of the
    ship, and his or her word goes," said Diane
    Rydrych, assistant director of the division of
    health policy at the Minnesota Health Department.
    "If there's a culture where people are afraid to
    say anything to the surgeon because they're
    afraid they're going to get yelled at, that's a
    problem."
  • Among surgeons, there is a "sense that I'm very
    well trained. I've done this procedure 100 times.
    It's not going to happen to me,'" she said.
    "Surgeons need that. You don't want an
    underconfident surgeon operating on you. But
    that's the downside."

Quality Patient Safety Lessons Learned from
other Industries
30
Responsibility vs. Protocol
  • (From an actual RCA Analysis)
  • The fact that many members of the health care
    team including resident physicians and nursing
    staff recognized the signs of fetal and
    neonatal compromise is commendable, however it
    is quite concerning that they felt unable or
    unwilling to seek other help when the attending
    physicians unwillingness to intervene became
    apparent.

Quality Patient Safety Lessons Learned from
other Industries
31
Responsibility vs. Protocol
  • (RCA continued)
  • It is possible that the rank structure of the
    military forms an inherent reluctance on the part
    of junior members to jump the chain of command
    when confronted with this situation. Likewise
    the subordinate role of the resident physician
    relative to the attending physician may impart a
    similar reluctance. We feel this is the main
    root cause of the operant event.

Quality Patient Safety Lessons Learned from
other Industries
32
  • "The only thing necessary for the triumph of evil
    is for good men to do nothing."
  • Edmund Burke

Quality Patient Safety Lessons Learned from
other Industries
33
  • Thanks
  • and
  • Remember

Quality Patient Safety Lessons Learned from
other Industries
34
  • Be Aware
  • Be Practical
  • Communicate
  • Change
  • Communicate

Quality Patient Safety Lessons Learned from
other Industries
35
  • Questions ?

Quality Patient Safety Lessons Learned from
other Industries
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