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Heroism vs Safety:please sir, may I have both ?
Peter Brindley MD FRCPC FRCP-EdinFull-time Clinician, and proud of it
Other Stuff: Professor: Critical Care Medicine; Ethics;
Anesthesiology
Division ofCritical Care Medicine
Declare your biases I
Prof Julian Bion
Physician def’n:• “A physician is a healthcare worker
authorized to work outside of guidelines”
smacc
Medicine: the most humane of the sciences;
the most scientific of the humanities
E Pellegrino
Declare your biases II:
smacc
The cold-hard truth (baker CMAJ 2004)
0200400600800
100012001400160018002000
Medical Auto Workplace Air
Deaths
A ZivWith permission
“Completely preventable ”
Neglected?
Brindley ‘10 Crit Care; Brindley et al’14 Can Resp J
“Care Gap”“Expectation Gap”“Education Gap”
“Science of managing complexity”
180 steps/pt/day
“Too much plane for one man to fly”
A Gawande, P Pronovost, many others
“Science of team performance”
# Steps Probability entire process correct
1 0.9525 0.2850 0.08100 0.06
LL Leape 1994; IHI. Preventing errors: the role of complexity.Pronovost PJ
“fit for task”?SIMPLE COMPLICATE
DCOMPLEX
EXAMPLE Bake Cake Fly to moon Raise child
PREDICTABILITY High Medium Low
EDUCATION Learn/ Practice
Break into steps
? Experience
STRATEGIES Task trainer Simulation ? Experience
Zimmermann and GloubermannA Gawande. Checklist Manifesto
“Engineering” Medicine
Reliability/ Resilience• S.O.P; Fail-safes
Knowledge exceeds the individual• Craftsmen Guilds Process engineers
Human factors, Team training• Engineering pressure tests a system-Simulation
Brindley P.G Crit Care 2010Brindley P.G ISICEM Yearbook 2010
W Dunn Chest/ D Angus/N Gibney communication
Human Factors, Crisis Management, Team
Work
Brindley. J Crit Care 2010
Personality
Team
Culture
Skate to where the puck will be
www.skygod.com/quotes
berkeley.edu/news/berkeleyan/1998/0225/coley.html
“it’s amazing how much you can achieve when nobody cares who gets the credit”
Culture Reinforcement
Which team do patients need?
“Team of experts is not an expert team”
• Obedience• Milgram & electric shock
• Conformity• Asch
• Play a role• Zimbardo & Stanford Prison
• Performance in different-sized teams• Dunbar
“Miracle on the Hudson”
“Sully Sullenberg”
“Captain America” “Hudson River Hero” “Le Nouveau Heros de l’Amerique”
The Pilot Not Flyingfewer planes crash when copilot flies
A Gawande 2009
PATIENT
Surgeons Physicians
Respiratory Therapist
Family Spiritual services
Pharmacy
“Medical Ergonomics”
“Ectopia”: land of danger
De Vita et al. & Trauma.orgS
L
A
S
S
Attudinia: equally dangerous!
• “Too early; too late”– The 7 yr hangover
• Hit the target; miss the point– Mid-Staffordshire inquiry– Elaine Bromiley
Brindley and Berger: J Crit Care 2009
Deep Blue(aka
Technology)
Garry Kasparov
(akaHuman)
• Pilots so reliant on computers…“they are forgetting how to fly”“automation addiction”
• 60% accidents; 30% major incidents
J Orr Aug 2011
Teaching beyond checklists?
“The blind learner”: a unique addition to CRM Brindley J Crit Care 2008”.
Flex lower c-spineFlex lower c-spine
Extend OA jointExtend OA joint
Ears in front of sternumEars in front of sternum
Sniffing posSniffing pos’’n n 1936 Magill 1936 Magill
Really?
Anatomic…………………………37% correct Sniff ……………………………….15% correct Win with the Chin………….43% correct Control…………………………… 20% correct
”Win with Chin” significantly better than sniff
Brindley et al. BJA 2010
Any Evidence?
A BIG BUTT
“SNIFF THE AIR” MADE YOU WORSE
5 cultural dimensions Geert Hofstede
Power distance index Inequality;
Individualism“Me” vrs “We”;
MasculinityAssertive;
UncertaintyRules vs Style
Long term orientationPersistence;
• “Culture eats data for breakfast”– Peter Drucker
Patient Safety vs Heroism 2.0
…What do patients need?
A.Factual Knowledge?B.Procedural dexterity?C.Communication/team
skills?
“Being an expert clinician means being an expert
communicator”Down a
bit
Up a bitStop!
In a bit
“You cannot NOT communicate”
“Meant is not said
Said is not heard
Heard is not understood
Understood is not done”
“Close the loop”
“Sterile cockpit”
“Mitigating language”
“levels of advocacy”
“Repeat back method”
“SBAR”
Cyna et al. Handbook of communication. 2014.Brindley. Can Resp J 2014
BETTER WORSE
Our most dangerous procedure!?
Many thanks