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Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

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Page 1: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health
Page 2: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

Pat Croskerry MD, PhD

The Safety CompetenciesEnhancing Patient Safety Across the Health Professions

Ottawa, October 2007

Health Profession Education for Patient Safety: Blink or Think?

Page 3: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

Canadian inter-professional competency-based framework

(institutional)

Medicine Nursing Pharmacy The therapy groups (PT, OT, RT)

Page 4: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

Four spheres ofFour spheres of educationaleducational influenceinfluence

Educators

Nurses

Managers

LegalSystem

Federal Government

Media

MedicalStudents

Supervisors

Administrators

GeneralPublic

CurrentPractitioners

Paramedics in Training

EquipmentSuppliers

Residents

HealthAdvisors

ProfessionalGroups

Ethicists

Local Government

AdvisoryGroups

PharmacyStudents

Multidisciplinary Training Groups

Blunt End

Socio-Legal Groups

Government

Provincial Government

Page 5: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

To identify the key knowledge, skills and attitudes related to patient safety competencies

for all health-care professionals

Page 6: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

Abilities that contribute to competenceAbilities that contribute to competence

Page 7: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

What kinds of abilities?What kinds of abilities?

Page 8: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

Critical Thinking and

Decision Making

Page 9: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

Critical Thinking

Page 10: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

Specific Abilities underlying Critical Thinking to know and understand Dual Process Theory to recognize distracting stimuli, propaganda, bias, irrelevance to identify, analyze, and challenge assumptions in arguments to be aware of cognitive fallacies and poor reasoning to recognize deception, deliberate or otherwise to assess credibility of information to monitor and control own thought processes to monitor and control own affective state to be aware of the impact of fatigue and sleep deprivation on decision making to be able to imagine and explore alternatives to effectively work through problems to be aware of the importance of the context under which decisions are made to make effective decisions to anticipate the consequences of decisions

Page 11: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

‘‘Those who are responsible for teaching students and Those who are responsible for teaching students and residents …should try to identify clearly, separate, residents …should try to identify clearly, separate, and then extract these critically important cognitive and then extract these critically important cognitive

tasks from courses that encompass myriad unrelated tasks from courses that encompass myriad unrelated skills and knowledge..’skills and knowledge..’

Kassirer, 1995

Page 12: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

Decision making

Page 13: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

How well do we How well do we make decisions?make decisions?

Page 14: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

The EmergenceThe Emergence of of

Dual Process TheoryDual Process Theory

Page 15: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

System 1 and System 2System 1 and System 2(how your brain works)(how your brain works)

Page 16: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

System 1(intuitive)

Cognitive style Cognitive style HeuristicHeuristicCognitive awareness Cognitive awareness LowLowCost Cost LowLowAutomaticity Automaticity HighHighRate Rate FastFastReliability Reliability LowLowErrors Errors UsuallyUsuallyEffort Effort LowLowPredictive power Predictive power LowLowEmotional component Emotional component HighHighScientific rigour Scientific rigour LowLow

System 2System 2 (analytical) (analytical) SystematicSystematic HighHigh HighHigh LowLow SlowSlow HighHigh FewFew HighHigh HighHigh LowLow HighHigh

Page 17: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health
Page 18: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

BlinkBlink Malcolm Gladwell (2005)Malcolm Gladwell (2005)

‘We really only trust conscious decision making. But there are moments, particularly in times of stress, when haste does not make waste, when our snap judgments and first impressions can offer a much better means of making sense of the world.

The first task of Blink is to convince you of a simple fact: decisions made very quickly can be every bit as good as

decisions made cautiously and deliberately’

P 14P 14

Page 19: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health
Page 20: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

ThinkThink Michael Legault (2006)Michael Legault (2006)

‘The technique by which we make good decisions and produce good work is a nuanced and interwoven mental process

involving bits of emotion, observation, intuition, and critical reasoning. The emotion and intuition are the easy, “automatic”

parts, the observation and critical reasoning skills the more difficult, acquired parts. The essential background to all this is a

solid base of knowledge.’

P 12P 12

Page 21: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

ContextAmbient conditionsModular responsivityTask difficultyTask ambiguityAffective state

EducationTrainingCritical thinkingLogical competenceRationalityFeedbackIntellectual ability

Pattern Recognition

Repetition

Rationaloverride

Dysrationaliaoverride Calibration Response

Patient SafetyProblem

PatternProcessor

RECOGNIZED

NOTRECOGNISED

System

11

System

22

Page 22: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health
Page 23: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

3 Features of the Model3 Features of the Model

Repetitive operations of System 2 Repetitive operations of System 2 System 2 override of System 1System 2 override of System 1 System 1 override of System 2System 1 override of System 2

Page 24: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

Repetitive Operations of System 2Repetitive Operations of System 2

Page 25: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

ContextAmbient conditionsModular responsivityTask difficultyTask ambiguityAffective state

EducationTrainingCritical thinkingLogical competenceRationalityFeedbackIntellectual ability

Pattern Recognition

Repetition

Rationaloverride

Dysrationaliaoverride Calibration Response

Patient SafetyProblem

PatternProcessor

RECOGNIZED

NOTRECOGNISED

System

11

System

22

Page 26: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health
Page 27: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

Repetitive Operations of System 2Repetitive Operations of System 2

KatecheoKatecheo Allows us to avoid redundancyAllows us to avoid redundancy Saves considerable time and resourcesSaves considerable time and resources Frees up our cognitive spaceFrees up our cognitive space Danger of being ‘too automatic’Danger of being ‘too automatic’

Page 28: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

System 2 override of System 1System 2 override of System 1

Page 29: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

ContextAmbient conditionsModular responsivityTask difficultyTask ambiguityAffective state

EducationTrainingCritical thinkingLogical competenceRationalityFeedbackIntellectual ability

Pattern Recognition

Repetition

Rationaloverride

Dysrationaliaoverride Calibration Response

Patient SafetyProblem

PatternProcessor

RECOGNIZED

NOTRECOGNISED

System

11

System

22

Page 30: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

System 2 override of System 1System 2 override of System 1

Feral vigilanceFeral vigilance Avoiding gut reactionAvoiding gut reaction Stop and thinkStop and think Sleep on itSleep on it

Page 31: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health
Page 32: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

System 1 override of System 2System 1 override of System 2

Page 33: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

ContextAmbient conditionsModular responsivityTask difficultyTask ambiguityAffective state

EducationTrainingCritical thinkingLogical competenceRationalityFeedbackIntellectual ability

Pattern Recognition

Repetition

Rationaloverride

Dysrationaliaoverride Calibration Response

Patient SafetyProblem

PatternProcessor

RECOGNIZED

NOTRECOGNISED

System

11

System

22

Page 34: Health Profession Education for Patient Safety” Blink or Think? Pat Croskerry MD, PhD The Safety Competencies Enhancing Patient Safety Across the Health

System 1 override of System 2System 1 override of System 2

Blue threatBlue threat Dysrational behavioursDysrational behaviours


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