Quality Patient Safety Lessons from other Industries

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Quality Patient Safety Lessons from other
Industries
Quality Patient Safety Lessons Learned from
other Industries
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Or making others best practices yours!
Quality Patient Safety Lessons Learned from
other Industries
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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
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• 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.

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other Industries
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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
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In Real Estate the mantra is location location
location
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other Industries
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For Teams, its Communication Communication
Communication!
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other Industries
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Why clear and accurate communication is so
important
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other Industries
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A panda walks into a café. He orders a sandwich,
eats it, then draws a gun and fires two shots in
the air.
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other Industries
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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.
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other Industries
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The waiter turns to the relevant entry, and sure
enough, finds an explanation.
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other Industries
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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
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• 2005 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.

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other Industries
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• Aviations Lessons Learned
• Adapting CRM
• Pre-Flight Briefings
• Post Flight Debriefs
• Mishap Investigations
• Analysis
• Reporting
• Includes Near Misses!

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• 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

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other Industries
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• 2006 Quality Colloquium Talk
• Team Training- Our Inconvenient Truth-Are you
  participating? the future of CRM and Team
  Training in Medicine
• focused on why wouldnt you have a team training
  program.

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other Industries
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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
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Communication errors alone account for over 70
of all patient related medical errors in both
Navy and civilian medical practices.
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other Industries
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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.
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other Industries
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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.
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other Industries
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• 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)

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other Industries
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• 2007 Quality Colloquium
• Conspicuously absent

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other Industries
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A Different Perspective about medical
teamsWhen a Doctor is the Patient
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other Industries
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• 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

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other Industries
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• At my last lecture, to a group of OR staff, an
  audience member 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.

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other Industries
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COLLABORATION WITH MY DOCTOR

• A brief recount of my experiences.

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other Industries
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COLLABORATION WITH MY DOCTOR

• 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.

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other Industries
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• 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
  Afghanistan.
• 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.

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other Industries
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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.

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other Industries
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• 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."

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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.

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other Industries
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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.

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other Industries
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• "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