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Grand Rounds December 7, 2011, SJRMC

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The High Reliability Emergency Department Grand Rounds December 7, 2011, SJRMC David J. Adinaro MD, MAEd, FACEP Chief, Adult Emergency Department, EM Residency ... – PowerPoint PPT presentation

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Title: Grand Rounds December 7, 2011, SJRMC


1
The High Reliability Emergency Department
  • Grand Rounds December 7, 2011, SJRMC

David J. Adinaro MD, MAEd, FACEP Chief, Adult
Emergency Department, EM Residency Research
Director
2
Disclosures
  • I have nothing to report in terms of financial
    disclosures.

3
Biases
  • I believe
  • That I have the best job in the world
  • That I work with the best people in the best
    profession
  • That we do noble work
  • That we can do better

4
Objectives
  • Understand the concept of HROs
  • Identify the similarities between EDs and other
    HROs
  • Identify ways to be more mindful in our everyday
    care of patients

5
Definitions
  • High Reliability Organizations

6
HRO
  • A High Reliability Organization (HRO) is an
    organization that has succeeded in avoiding
    catastrophes in an environment where normal
    accidents can be expected due to risk factors and
    complexity

7
Definitions
  • A NORMAL ACCIDENT or SYSTEM ACCIDENT is an
    unanticipated interaction of multiple failures
    in a complex system.
  • Requires both INTERACTIVE COMPLEXITY and TIGHT
    COUPLING to be present in the system.

8
Reasons Model of Normal Accidents
9
Example of Normal Accident
  • Trauma patient suddenly becomes unresponsive and
    apneic shortly after extubation s\p diagnostic
    work up in the Emergency Department of a Level I
    trauma center.
  • Requires emergent reintubation for a short period
    of time.

10
Example of Normal Accident
  • Hospital policy of properly labeling unmarked
    meds not routinely followed.
  • Standardized labeling not available.
  • Teams performing intubations do not routinely
    ensure\witness proper disposal of dangerous
    medications.

11
Example of Normal Accident
  • In order to flush Hep Lock nurse uses apparently
    unused normal saline in 10cc syringe left at
    bedside
  • Prepackaged flushes not routinely available so NS
    generally drawn into similar 10cc syringes.

12
Example of Normal Accident
  • RESULTS Patient is unintentionally injected with
    60-80mg of Succinylcholine.

13
Example of Normal Accident
  • Take a moment to write down an example of a
    NORMAL ACCIDENT you witnessed, participated in,
    and\or prevented recently.

14
Reasons Model of Normal Accidents
15
Environment of an HRO
  • Hypercomplexity - HROs exist in complex
    environments that depend on multi-team systems
    that must coordinate for safety
  • Tight coupling - HROs consist of tightly coupled
    teams in which the members depend on tasks
    performed across their team
  • Extreme hierarchical differentiation - In HROs,
    roles are clearly differentiated and defined.
    Intensive coordination efforts are needed to keep
    members of the teams working cohesively
  • Multiple decision makers in a complex
    communication network - HROs consist of many
    decision makers working to make important,
    interconnected decisions
  • High degree of accountability - HROs have a high
    degree of accountability when an error occurs
    that has severe consequences
  • Need for frequent, immediate feedback - HROs
    exist in industries where team members must
    receive frequent feedback at all times
  • Compressed time constraints - Time constraints
    are common to many industries, including health
    care

16
HRO Principles
  • 1) Preoccupation with failure
  • 2) Reluctance to simplify
  • 3) Sensitivity to operations
  • 4) Commitment to resilience
  • 5) Deference to expertise

17
HRO
  • Aircraft carrier flight operations
  • Nuclear Power Plants
  • Fireground Operations (especially wildfire)
  • Emergency Departments!

18
HRO Principle 1
  • Preoccupation with failure
  • Encourage reporting of errors
  • Treating any lapse as a symptom that something
    may be wrong with the system.
  • Using near-misses for what can be learned.
  • Accepting that small failures can have an
    additive effect and lead to Natural Accidents.
  • Continually articulating mistakes they dont want
    to make.

19
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20
HRO Principle 1
  • Preoccupation with failure
  • Naval Flight Operations
  • Obsessed with finding failure.
  • Every landing is televised, reviewed, graded, and
    grades used to improve performance.
  • Everyone sees how everyone else performs.
  • Near Misses
  • Debriefed within the hour.
  • Everyone documents what they saw and\or heard
    prior to incident.
  • Treated as signs of potential larger problems.

21
Crashes spur Navy to ground all its aircraft
for safety review ACROSS THE NATION March 05,
2006By Items compiled from Tribune news
services. WASHINGTON, D.C. Plagued by a series
of helicopter and jet crashes in recent months,
the Navy has decided to ground all its aircraft
for half a day this week for an internal safety
review. The stand-down will affect 3,800 aircraft
and thousands of naval aviation personnel,
including aircraft on 12 carriers around the
world. It is the first time since 1997 that such
a pause in flight operations across the Navy has
been ordered. Since Oct 1. there have been major
crashes that resulted in loss of life or of the
aircaft. Nine aircraft were destroyed and 10
aviators killed.
22
HRO Principle 1
  • Preoccupation with failure
  • Examples of Violations
  • Bent Spear USAF Nuclear Weapons Incident
  • Warheads left without special protections for 36
    hours after mistakenly being loaded on B52
  • Investigations show multiple near misses prior.
  • Resignations starting with Secretary of Air
    Force.
  • Changes to handling procedures\training.

23
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24
HRO Principle 1
  • Preoccupation with failure
  • Examples of Violations
  • Cerro Grande Fire
  • Planned Prescribed Fire of 300 acres near Santa
    Fe, NM. to reduce risk of wildfires.
  • Crew of 20 Firefighters ignite a 3 foot perimeter
    before planning to burn interior.
  • Failures noted to contain perimeter fires prior
    to burn of interior.
  • 15 days later fire finally under control after
    being fought by 1,000 firefighters burning 48,000
    acres and causing 1 billion in damage.

25
HRO Principle 1
  • Preoccupation with failure
  • Emergency Department
  • Incident Reporting
  • EDQA Process
  • 400 charts and still going
  • Large focus on systems issues
  • Need to change disincentives for reporting
    errors.
  • Need to recognize near-misses as small failures.

26
HRO Principle 2
  • Reluctance to Simplify
  • Less Simplification Broader awareness.
  • A view that the world is complex, unstable,
    unknowable, and unpredictable.
  • Welcomes diverse experience, skepticism toward
    received wisdom.
  • Understands that superficial similarities between
    the present and the past mask deeper differences
    that could prove fatal.
  • Mindfulness to have a rich awareness of
    discriminatory detail and enhance ability to
    discover and correct errors that could escalate
    into a crisis.

27
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28
HRO Principle 2
  • Reluctance to Simplify
  • NASA (Columbia Space Shuttle Accident)
  • Tendency to simply problems.
  • Distinction between in-family and
    out-of-family problems.
  • In-family label used for problems already
    analyzed and understood.
  • Burn marks to O-Rings noted on earlier flights.
  • After analysis this was determined to be an
    in-family problem.

29
HRO Principle 2
  • Reluctance to Simplify
  • NASA (Columbia Space Shuttle Accident)
  • Continued concerns about O-Rings ignored as they
    were already determined in-family.
  • Multiple waivers granted related to O-rings.
  • January 28, 1986 Challenger broke apart 73
    seconds into launch.
  • All seven astronauts including civilian teacher
    killed.

30
HRO Principle 2
  • Reluctance to Simplify
  • Emergency Department
  • Commitment to mindfulness.
  • Is that patient supposed to look that way????
  • Overcoming reluctance to express concerns.
  • Responding immediately to others concerns.
  • Actively searching for disconfirming data.

31
HRO Principle 2
  • Reluctance to Simplify
  • Emergency Department
  • Simplification a major source of diagnostic
    medical error.
  • Frequently physicians cut off exploration of
    patients condition too early.
  • Use of pattern recognition a double-edged sword.
  • Often results in closest fit approach.
  • Results in missed diagnoses and delayed care.
  • Classic example is overdiagnosis of
    gastroenteritis in other serious conditions
    (appendicitis, etc.)
  • Healthy skepticism and accounting for all
    findings help prevent these errors.

32
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33
HRO Principle 3
  • Sensitivity to Operations
  • Attentive to the front line.
  • Sensitivity to Relationships.
  • Ensures resources needed to accomplish mission
    are available.
  • Works hard to break down silos.
  • Encourages communication within and between
    departments.
  • Attempts to keep focus on the Big Picture .
  • Processes a near miss not as success (I caught
    the patient before she strangled herself) but as
    a small failure ((failure to identify and respond
    to suicide risk).
  • Looks for small wins in improving system.

34
HRO Principle 3
  • Sensitivity to Operations
  • Wildland Firefighting
  • Standard analysis of all fires to find errors and
    ways to improve.
  • Adherence to 10 Standard Fire Orders
  • Keep informed of conditions.
  • Know what your fire is doing at all times.
  • Identify escape routes and safety zones.
  • Be alert. Keep calm. Think clearly. Act
    decisively.
  • Give clear instructions and insure understanding.
  • 10) Fight fire aggressively, having provided
    safety first.

35
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36
HRO Principle 3
  • Sensitivity to Operations
  • Storm King Tragedy (South Canyon Fire 1994)
  • 14 highly experienced firefighters lose their
    lives when the fire jumps the line they were
    digging trapping them on a ridge.
  • Overly aggressive tactics combined with lack of
    support and no planned escape route.
  • Warning of high winds not communicated.
  • Later determined leadership at fire scene also
    lacking.

37
ED Operations
PICTURE
38
HRO Principle 3
  • Sensitivity to Operations
  • Emergency Department
  • Communication, communication, communication.
  • Communicate up, down and around.
  • Never assume other possess what you know.
  • Report near-misses. Treat them seriously.
  • Look for the small wins.

39
HRO Principle 3
  • Sensitivity to Operations
  • Emergency Department small wins
  • Small Wins produce change without confronting
    the system directly or aggressively.
  • Recent examples
  • Use of Admin sign to denote pending bed
    assignment.
  • Pneumonia ABX guide.
  • Physician Reference guide.
  • Impact is from examples they provide others.
  • Through doing something tangible.
  • Through showing change is possible.

40
HRO Principle 3
  • Sensitivity to Operations
  • Emergency Department small wins
  • Write down an issue ripe for a small win.

41
HRO Principle 4
  • Commitment to Resilience
  • Intrinsic ability of a system to maintain or
    regain a dynamically stable state, allowing
    continued operations after a major mishap or in
    presence of continuous stress.
  • Involves recognition that no system is perfect.
  • Combination of keeping errors small and of
    improvising workarounds to keep system
    functioning.

42
HRO Principle 4
  • Commitment to Resilience
  • Emergency Department.
  • We own this hands down.
  • We operate in a near continual state of stress
    that requires significant resilience.
  • Our motto Anyone, Anything, Anytime.
  • Nuff said.

43
HRO Principle 5
  • Deference to Expertise
  • Pushes decision making down and around.
  • Decisions are made on the front line.
  • Authority migrates to the people with the most
    expertise.
  • Makes an effort to see what people with greasy
    hands know.
  • Does not mistake expertise with experts.

44
HRO Principle 5
  • Deference to Expertise
  • Emergency Department
  • At times goes against the hierarchal nature of
    medicine.
  • Does fit in well with the golden rule (when in
    doubt.consult).
  • Dependent on the free flow of information and
    respect for colleagues.
  • Made easier when focus is on Big Picture.
  • Not a sign of weakness.

45
SJRMC ED Operations
  • Embraces many aspects of HRO.
  • Expectation of continued improvement and need for
    change is most important asset.
  • Improving communication is crucially important.
  • Feedback from the sharp end is vital.
  • Adinarod_at_sjhmc.org
  • Office 973-754-3735.

46
Thank You!
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