Observatie in de OK

Martijn Kriens @martijnkriens, martijn.kriens@icrowds.net

The old operating theatre, London

Martijn Kriens Medical Data Recorder

Research

Quality Assurance

Pilot

@martijnkriens, martijn.kriens@icrowds.net

Human Fallibility

Systemic learning

Medical Data Recorder

Human FallibilityTruth emerges more readily from error than from confusion

Francis Bacon

TO HUMANISERR

TO BE HUMAN IS TOERR

We nemen het anderen meer kwalijk dat ze onze fouten kennen, dan onszelf dat wij daaraan mank gaan.

Multatuli

We hold it more against others to know our failures, than to hold our failures against ourselves

Multatuli (Dutch writer)

0,0%

0,4%

0,8%

1,2%

1,6%

Diagnose Surgical Treatment Medication Care Release Others

200420082012

Surgery is responsible for 60% of all Avoidable Errors (22.500)

Monitor Zorggerelateerde Schade 2008, NIVEL

Direct costs are > 125M euro per year

Systemic learningI am always ready to learn although I do not always like to be taught

Winston Churchill

© Medical Data Recorder

KLM (RADIO) Ah roger, sir, we are cleared to the Papa Beacon flight level nine zero until intercepting the three two five. We are now at take-off …TENERIFE TOWER OK....[static noise]... (KLM initiates take-off) TENERIFE TOWER Ah, papa alpha one seven three six report the runway clear.PAN AM (RADIO) OK, will report when we're clear. ... KLM FLT ENGR (CVR) [Is he not clear, that Pan American?] KLM CAPTAIN (CVR) [Oh yes. - emphatic]

[Pan Am captain sees landing lights of KLM Boeing at approx. 700 m] PAN AM CAPTAIN There he is ... look at him. Goddamn that son-of-a-bitch is coming!

http://planecrashinfo.com/cvr770327.htm

KLM (RADIO) Ah roger, sir, we are cleared to the Papa Beacon flight level nine zero until intercepting the three two five. We are now at take-off …TENERIFE TOWER OK....Stand by for take-off, I will call you.... (KLM initiates take-off) TENERIFE TOWER Ah, papa alpha one seven three six report the runway clear.PAN AM (RADIO) OK, will report when we're clear. ... KLM FLT ENGR (CVR) [Is he not clear, that Pan American?] KLM CAPTAIN (CVR) [Oh yes. - emphatic]

[Pan Am captain sees landing lights of KLM Boeing at approx. 700 m] PAN AM CAPTAIN There he is ... look at him. Goddamn that son-of-a-bitch is coming!

PLANE1234: [call sign] ready for departure at Runway three zero

TOWER: [call sign], you are cleared for take off Runway three zero

PLANE5678: [call sign] Runway vacated

Lesson Tenerife

Aviation safety

Quality Assurance

Patient safety

Checklists Procedures

Training syllabi communication

Surgical education Improvement begins with I

Arnold Glasow

Not Received 7%Not Transmitted 49% Misunderstanding 44%

Patterns of Communication Breakdowns Resulting in Injury to Surgical Patients, Greenberg, 2007

Failures due to communication errors (60 out of 258)

Plan

Do

Check

Act

Crew Resource

Management (CRM)

Medical Data

Recorder (MDR)

Assurance in processes

Improvement ofprocesses

Plan the proces - checklists, …

Do according to agreed processes

Check expected outcomes with

reality

Act on deviations - analise and adapt

Stop and count to 10

Think about your options

Do what you think is best

V

V

V

Checklists

Pause points• Preparation• Team start• Incision• Reach target• Treatment• Repairing• Closing• Hand-over

• Risks / abnormalities • Pre-conditions • Postconditions • Checks • Activities} {

(my) Observations

• High fault tolerance

• Strong hierarchy

• Going through the motions of checklists

• Attention to standard process

• Chasm between disciplines

http://www.icrowds.net/2014/01/observatie-in-de-operatiekamer/

Antic

ipat

ion

Cont

aim

ent

• Preoccupation with failure• Actively find failures and learn

• Reluctance to simplify– Challenge beliefs, don’t stop asking why

• Sensitivity to operations• Grasp context and flow

• Commitment to resilience• Discipline, know what is important

• Deference to expertise– Open channels

http://www.beckershospitalreview.com/hospital-management-administration/5-traits-of-high-reliability-organizations-how-to-hardwire-each-in-your-organization.html?goback=%2Egde_4877284_member_240196966

High reliability organisations

FailureSucces

? ? ?

• Collective memory• Shared stories

• Evidence based processes• organizational quality

• Team focus• Hierarchy

• An error does not imply guilt

© Medical Data Recorder

Less

ons

for s

urge

ry

Medical Data RecorderFacts do not cease to exist because they are ignored.

Aldous Huxley

More than 50% of operation reports do not describe what really happened

LearningProsecution

Vision&and&sound

Data&from&sensors

Tagging activities

S

ASSNCN

A

AA

Camera

Microphone

Thank you

Martijn Kriens