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NOW, IT IS MY DISTINCT HONOR TO
WANT TO WELCOME LAURA LEE TO THE
NIH CLINICAL CENTER.
AND I NOTICE A LOT OF PEOPLE
HERE HAVE BEEN GREETING HERE AND
THERE HAS BEEN A LOT OF GREAT
CONVERSATIONS ALREADY.
SO I WILL GO TO INTRODUCE HERE,
LAURA LEE HOLDS A BACHELOR OF
SCIENCE OF NURSING FROM THE
CATHOLIC UNIVERSITY OF AMERICA,
A BACHELOR OF ARTS IN BUSINESS
ADMINISTRATION, AND A MASTER OF
SCIENCE IN PATIENT SAFETY
LEADATROM THE COLLEGE OF
MEDICINE AT THE UNIVERSITY OF
ILLINOIS, CHICAGO.
AT MEDSTAR HEALTH, SHE IS
CURRENTLY ASSISTANT VICE
PRESIDENT FOR PATIENT SAFETY,
LAURA LEE WAS THE OFFICE OF
PATIENT SAFETY AND CLINICAL
QUALITY HERE AT THE NIH CLINICAL
CENTER.
A ESSENTIAL ASPECT OF HER
RESPONSIBILITIES AT THE HOSPITAL
WAS ENSURING THE PROVISION OF
SAFE AND HIGH QUALITY PATIENT
CARE INRE A CLINICAL RESEARCH
ENVIRONMENT.
IN HER CURRENT ROLE AS ASSISTANT
VICE PRESIDENT, SHE PLAYS A
CRUCIAL PART IN DEVELOPING AN
OPERATIONINALLIZING MEDSTAR
HEALTH STRATEGIC INITIATIVES AND
MEDSTAR HEALTH IS QUITE A LARGE
HEALTH SYSTEM HERE IN THE DC
AREA.
LAURA LEE BRINGS THE HIGHER
LIABILITY TO LIFE AT THE FRONT
LINE OF CARE DELIVERY AND
HEALTHCARE OPERATIONS AND
STST TO ADVANCE MEDICAL
EDUCATION WITH A SAFE AND JUST
CULTURE AND PROACTIVE SAFETY
PROVISIONS THAT ANTICIPATE AND
PREVENT HAZARDS AND UNSAFE
CONDITIONS.
LAURA LEE HAS BEEN AWARDED A NIH
HONOR AWARD FOR SAFETY
IMPROVEMENTIM IN 2020 AND HHS
SECRETARY AWARD FOR SERVICE, AND
NIH CLINICAL CENTER CEO AWARD
FOR PATIENT SAFETY CHAMPION IN
2019.
THE TITLE OF TODAY'S
PRESENTATION IS STRUCTURED
PATIENT SAFETYIONS.
WELCOMINGE JOINT ME IN
TODAY'S GRAND ROUND SPEAKER,
LAURA LEE.
[ APPLAUSE ]
>> LAURA: THANK YOU FOR THE
WONDERFUL INTRODUCTION.
I MET YOU AT THE DOOR LIKE I HAD
IN 30 YEARS.
IT IS WONDERFUL.
WE WILL GET STARTED IN THE
INTEREST OF TIME.
I WILL TALK TO YOU ABOUT SAFETY
SCIENCE.
WHERE I COME FROM, MEDSTAR
HEALTH IS THE BIGGEST HEALTH
SYSTEM HERE IN THE
BALTIMORE/WASHINGTON AREA.
10 HOSPITALS, ALMOST 300 PRIMARY
CARE SITES.
32 EMPLOYEES.
WE'VE GOT ABOUT 1100 RESIDENTS
AND INTERNS AND FELLOWS AND
TRAINEES.
WE HAVE RESEARCH INSTITUTE, OUR
MEDSTAR HEALTH RESEARCH
INSTITUTE.
WE HAVE OUR INSTITUTE FOR
QUALITY AND SAFETY.
WE HAVE A HUMAN FACTORS
INSTITUTE.
SO IT IS SORT OF LIKE A
PLAYGROUND TO GO AND DO PATIENT
SAFETY.
SO WE DO HAVE A PRETTY
SUBSTANTIAL RESEARCH PORTFOLIO.
SO WE GET TO DABBLE A LITTLE BIT
IN THAT, I SORT OF GET MY
CLINICAL RESEARCH JUICES FLOWING
A LITTLE BIT EARLY ONCE IN A
WHILE.
IT IS GOOD TO HAVE THAT
CONNECTION.
SO WHAT ARE WE GOING TO DO
TODAY?
WE ARE GOING TO TALK ABOUT HOW
WE ARE NOT SAFE IN HEALTHCARE,
AND SAFETY SCIENCE AND HUMAN
FACTORS ENGINEERING AND THE SORT
OF THEORY BEHIND ERRORS.
BECAUSE IN OUR VIEW, YOU HAVE TO
HAVE THAT FOUNDATION IN ORDER TO
MAKE CHANGES THAT ARE FEASIBLE
AND SUSTAINABLE.
TALK A LITTLE BIT ABOUT
REPORTING EVENTS AND HOW
IMPORTANT THAT IS TO YOUR
PATIENTS, TO YOU, AND TO YOUR
ORGANIZATION.
REALLY GETTING TO WHY EVENTS
OCCUR AND TAKING THAT SYSTEM'S
VIEW.
AND THEN, TALKING A FAIR AMOUNT
ABOUT HOW WE CAN DESIGN SAFETY
INTO SYSTEMS SO THAT WE KEEP
HARM OUT.
SO, WE'RE GOING TO START WITH A
LITTLE QUIZ.
SOME OF YOU MAY BE FAMILIAR WITH
THIS.
THIS IS A GRAPH THAT SHOWS US
THE RELATIVE RISK ASSOCIATED
WITH ACTIVITIES ACROSS
EVERYTHING THAT WE DO IN LIFE.
SO ON THE Y AXIS WE HAVE THE
TOTAL LIVES LOST PER YEAR.
ON THE X AXIS THE NUMBER OF
ENCOUNTERS FOR EACH FATALITY.
ALL OF THE WAY ON THE LEFT-HAND
SIDE, WE SEE DANGEROUS
ACTIVITIES LIKE MOUNTAIN
CLIMBINGS AND BUNGEE JUMPING.
IN THE MIDDLE MORE REGULATED,
DRIVING, CHARTERED FLIGHTS,
CHEMICAL MANUFACTURING.
AND ON THE RIGHT ARE THE ALTER
SAFE ORGANIZATIONS, HIGH
RELIABILITY ORGANIZATIONS THAT
ARE REALLY RIFFINGY BUSINESS AND
IF SOMETHING BAD HAPPENS THERE
OUTCOME CAN BE CATASTROPHIC, BUT
FOR WHATEVER REASON, THEY ARE
HIGH RELIABILITY ORGANIZATIONS
THERE IS VERY FEW INCIDENCES.
SO WHERE DO WE THINK HEALTHCARE
FALLS ALONG THIS CONTINUE!
HOW MANY PEOPLE SAY ULTRA SAFE?
OKAY, HOW MANY PEOPLE SAY
REGULATED?
HOW MANY PEOPLE SAY DANGEROUS.
OKAY.
YEP, RIGHT THERE.
WE'RE RIGHT THERE WITH BUNGEE
JUMPING.
SO, OUR PATIENTS GO THROUGH THE
THRESHOLD ANY DOOR IN ANY
HOSPITAL IN THE UNITED STATES,
THEY THINK THEY ARE GOING TO BE
CARED FOR, WE THINK WE ARE GOING
TO TAKE CARE OF THEM, BUT IT IS
THE SAME AS WRAPPING A RUBBER
BAND TO SOMEONE'S WAIST AND
PUSHING THEM OFF A BRIDGE.
TO US, THAT IS UNACCEPT.
WE NEED TO FIGURE OUT WHAT IS
KEEPING US, WHAT INFLUENCES ARE
OUT THERE THAT ARE KEEPING US
FROM DOING THE RIGHT THING.
SO I LOVE THIS QUOTE, MEDICINE
USED TO BE SIMPLE, INEFFECTIVE,
AND RELATIVELY SAFE.
THINK LEECHES.
NOW, IT IS COMPLEX, EFFECTIVE,
AND POTENTIALLY DANGEROUS.
AND ACTUALLY, IN THIS
ENVIRONMENT, IN THE CLINICAL
CENTER, THAT HOLDS REALLY TRUISM
ESPECIALLY SINCE WE'RE DOING
CLINICAL TRIALS, WE, I SAID
WE'RE DOING, Y'ALL ARE DOING
CLINICAL TRIALS, PHASE I, PHASE
II, PROOF OF PRINCIPLE, FIRST IN
HUMAN.
IF THERE IS EVER A PLACE WHERE
THIS STATEMENT IS HOLDS TRUE IT
IS HERE AT THE CLINICAL CENTER.
YOU KNOW, THE INSTITUTE OF
MEDICINE REPORT WAS ISSUED IN
1999, THE FIRST TIME THIS WHOLE
ISSUE OF HARM RELATED TO
MEDICINE AND GOING INTO A
HOSPITAL REALLY CAME OUT.
WE'RE STILL REALLY NOT THAT MUCH
SAFER.
THIS A STUDY DONE BY FOLKS,
DAVID BITES AT THE HARVARD
GROUP, PUBLISHED IN 2024,
EARLIER THIS YEAR, AND THEY
LOOKED AT ALL OF THE DATA FOR
THE LAST, IN 2023 AND EARLIER
AND WE REALLY HAVEN'T GOTTEN
MUCH SAFER.
SO WE AS AN ORGANIZATION, AS A
HEALTHCARE COMMUNITY, HAVE TO
FIGURE OUT HOW TO DO BETTER AND
RELYING ON SAFETY SCIENCE AND
THINGS LIKE THAT WILL HELP US DO
THAT.
SO WE ARE A REALLY COMPLICATED
AND MESSY INDUSTRY.
WHERE THIS COMPLEX SOCIAL
TECHNICAL ENVIRONMENT THAT HAS
THESE THREE BIG FACTORS THAT
INFLUENCE EVERYTHING WE DO.
WE HAVE ALL OF THE SYSTEMS
ISSUES, WHERE IT IS
ORGANIZATIONAL STRUCTURE,
CULTURE, HOW WE'RE FINANCED, HOW
WE'RE FUND FROM CONGRESS.
THOSE ARE INFLUENCE HOW WE CAN
MANAGE SAFETY.
THEN WE HAVE PROCESSES.
YOU KNOW, WE ARE JUST ONE BIG
BALL OF PROCESSES.
WHETHER IT'S CLINICAL RESEARCH
PORT CALL OR CLINICAL PRACTICE
GUIDELINES.
SOPs WE'RE NOT DOING THEM IN A
NICE TIDY COP PIT OF AN
AIRPLANE, OR A NICE PRES STEIN
FACTORIES WERE WIDGETS COME OFF,
WE'RE DOING IN THE IN A MESSY
INDUSTRY, LIKE HEALTHCARE, AND
THEN WE ADD ON HUMANS WHICH WE
ARE NOT PREDICTABLE AND MAKE
MISTAKES, US AS HUMANS, PATIENTS
THAT ARE SICK AND HAVE IMPORTANT
NEEDS AND WHEN YOU PUT ALL OF
THOSE THINGS TOGETHER IT IS
REALLY, REALLY COMPLICATED
ENVIRONMENT.
WE NEED TO RELY ON SAFETY
SCIENCE AND NEED TO RELY ON WAYS
TO UNDERSTAND EVENT HASICATE
HAPPEN TO KEEP OUR PATIENTS SAFE
IN THE FUTURE.
SO, SAFETY SCIENCE, WE'RE GOING
TO TALK ABOUT HUMAN FACTORS
ENGINEERING AND SORT OF THE
THEORY OF ERRORS.
SO, WE USE THIS STATEMENT A LOT
WHERE I COME FROM.
WE CAN'T REDESIGN HUMANS BUT WE
CAN REDESIGN THE SYSTEMS IN
WHICH WE ASK PEOPLE TO DO THE
WORK.
THAT'S WHERE HUMAN FACTORS
ENGINEERING COMES IN.
SO HUMAN FACTORS ENGINEERING IS
SIMPLY THE SCIENCE OF HOW PEOPLE
DO WORK.
OR HOW THEY CONNECT WITH OTHER
PEOPLE.
OR THEIR ENVIRONMENT OR THEIR
TECHNOLOGY.
AND BY LOOKING AT THAT, IT
UNDERSTANDING HUMAN
CAPABILITIES, THEN WE CAN
REDESIGN OUR PRODUCTS, OUR
PROCESSES, OUR TOOLS BASED ON
WHAT IT MEANS TO BE HUMAN.
SO, THE TWO GRAPHICS AT THE
BOTTOM OF THE SLIDE, ERGONOMICS,
HOW YOU DESIGN A PIECE OF
EQUIPMENT SO SOMEONE THAT IS 5-2
CAN USE IT AS EASILY AS SOMEONE
WHO IS 6-5.
I DON'T KNOW HOW MANY ARE
FAMILIAR WITH THE ONGOING WAR OF
SUNS VERSUS SERIF FONT, YOU NEED
TO GOOGLE IT, BUT IT IS THE
SAME, WHICH OF THESE FONTS IS
BETTER FOR WHICH TYPE OF PERSON
DOING THE READING.
THESE ARE ALL HOW WE AS HUMANS
INTERACT WITH SOMETHING THAT IS
PUT IN FRONT OF US.
SO, HOW MANY OF YOU HAVE PUSHED
A DOOR WHEN YOU WERE SUPPOSED TO
PULL?
RIGHT?
I KNOW.
AND IF ANYBODY'S BEEN TO
BETHESDA BAGELS, THAT DOOR I RUN
INTO WITH MY NOSE EVERY TIME I
GO IN.
THIS WITH A REALLY BAD DESIGN.
AS A HUMAN I'M GETTING SO MANY
MIXED MESSAGES, I SHOULD PULL
THAT HANDLE, BUT YOU'RE TELLING
ME TO PUSH.
I'M NOT GOING TO MAKE THE
MISTAKE HERE.
THIS DESIGN HELPED ME AVOID
ERROR AND HARM TO MY NOSE.
HERE ARE EXAMPLES HOW HUMAN
FACTORS HAVE INFLUENCED DEVIBE.
SO IT HELPS ANTICIPATE ERRORS.
THIS IS AN EMAIL THAT SAYS I
ATTACHED THIS MONTH'S REPORT, I
TRY TO SEND IT AND GET A NICE
NOTE THAT SAYS, HEY, YOU FORGOT
TO ATTACH SOMETHING, DID YOU?
IT KEPT ME FROM MAKING AN ERROR.
THIS DESIGN PREVENTS ME FROM
DOING AN ERROR.
YOU CAN'T START YOUR MICROWAVE
WITH THE DOOR STILL OPEN, IT IS
JUST IMPOSSIBLE.
MAKING IT HARD TO DO THE WRONG
THING IS SORT OF A MAJOR TENANT
OF HUMAN FACTORS AND MAKING IT
EASY TO DO THE RIGHT THING.
SO MANY OF YOU IN THE ROOM MAY
REMEMBER WHEN NOZZLES ON GAS --
WHATEVER THE THING ON THE GAS
TANK, WHAT IS THAT CALLED?
THE NOZZLE, WHERE, WERE THE SAME
SIZE, SO YOU COULD EASILY PUT
DIESEL FUEL INTO A REGULAR
ENGINE, MOUTH THEY ARE DIFFERENT
SIZES.
SO YOU CAN'T POSSIBLY DO THAT
ANYMORE.
THEN THIS IS ONE OF MY FAVORITE
HUMAN FACTORS DESIGN ISSUES,
THIS IS, YOU KNOW, YOU HAVE TO
HAVE 10, 10 CHARACTERS IN YOUR
PASSWORD, I CAN NEVER REMEMBER
IF HAVE DONE THE SPECIAL
CHARACTER OR NOT.
THIS IS JUST MY CUE CARD FOR
THAT.
SO IT MAKES IT REALLY EASY FOR
ME TO DO THE RIGHT THING IN LESS
TIME.
BUT CAN WE DO THAT IN HEALTHCARE
WITH ALL OF THE COMPLEXITY?
TAKE A QUICK LOOK AT THIS
PICTURE.
AND WHAT YOU SEE ARE A BUNCH OF
MACHINES AND, YOU KNOW, I'M SURE
IF WE HAD AUDIO FOR THIS, WE
WOULD HEAR A LOT OF BEEPS AND
ALARMS AND WORDS AND THINGS LIKE
THAT.
THE VERY CENTER OF IT, THOUGH,
IS OUR, WAS VULNERABLE PATIENT.
A LITTLE NEONATE.
SO THINK ABOUT THE COMPLEXITY OF
HEALTHCARE IN EVERYTHING THAT'S
GOING ON IN THAT ROOM.
AND THE CONTEXT OF KEEPING THAT
LITTLE ONE SAFE.
AND HOW DO WE DO THAT?
WE CAN APPLY HUMAN FACTORS TO
THAT.
SO THIS IS AN EXAMPLE OF A CASE
THAT WAS MANY YEARS AGO, BUT WE
LOVE THIS QUOTATION.
THIS WAS A CASE OF A NURSE WHO
GAVE A CATASTROPHIC
MISADMINISTRATION, SHE JUST
SIMPLY HUNG THE WRONG IV.
THEY INTERVIEWED HER PART OF THE
ANALYSIS.
THIS IS WHAT SHE SAID, I THINK
SHE WAS CHARGED.
I GOT HER IV.
HER ANTIBIOTIC AND HER EPIDURAL
BAG.
BOTH BAGS HAVE ENDS THAT
RECEIVED IV TUBING.
I HAD HER ANTIBIOTIC IN MY HAND.
I KNEW THAT, BUT I DIDN'T HAVE
HER ANTIBIOTIC AND HAD HER
EPIDURAL MEDICATION.
AND IT RESULTED INNING A
CATASTROPHIC INJURY TO TO THE
PATIENT.
I APOLOGIZE FOR THE BLURRINESS
OF THESE SLIDES, BUT IT IS VERY
EASY, MULTITASKING, HAVE A BUNCH
OF SICK PATIENTS, OVERLY
STRESSED IN IN -- HURRY, YOU
CAN MAKE A MISTAKE.
SHE KNEW BETTER.
SHE KNEW SHE WAS SUPPOSED TO BE
HANGING THE ANTIBIOTIC AND NOT
THE EPIDURAL.
BUT SHE JUST MADE A SLIP.
SO, WHAT WOULD HAPPEN IF YOU
CONFUSE THESE PRODUCTS?
ON THE LEFT-HAND SIDE, YOU SEE
TWO VIALS, VERY SIMILAR IN SIZE,
SHAPE, COLOR OF THE FLUID, ONE
IS POTASSIUM CHLORIDE AND THE
OTHER IS SODIUM CHLORIDE.
THAT COULD BE A CATASTROPHE
ERROR AS WELL.
MY FAVORITE ONE IS IN THE
MIDDLE, THEY ARE EYE DROPS FOR
SOMEONE HAVING VISION PROBLEMS,
HOW CAN YOU TELL THE DIFFERENCE
BETWEEN THE TWO MEDICATIONS.
AND THEN THE LITERATURE IS JUST
FULL OF EXAMPLES OF WHERE WE
HAVE MIXED UP MEDICAL GASES.
BUT HUMAN FACTORS CAN HELP US
WITH THAT.
ON THE UPPER LEFT-HAND SIDE,
THIS IS A COMPANY THAT HAS
REALLY ENGINEERED MEDICAL GAS
MISTAKES OUT OF OUR, OUT OF
THEIR WORLD.
THEY ARE DIFFERENT COLORS, THEY
ARE COLOR-CODED WITH THE
REGULATOR THAT NEEDS TO GO ON.
IF YOU CAN SEE THE LITTLE KNOBS
IN EACH OF THE -- THE OUTLETS
THERE ARE A LITTLE BIT
DIFFERENT.
SO YOU COULDN'T POSSIBLY PUT THE
WRONG REGULATOR INTO IT.
IF YOU LOOK DOWN HERE, THIS
IS -- THIS IS FROM EHR WORK.
WHERE YOU, YOU -- YOU GUYS HAVE
THAT HERE IN YOUR EHR AS WELL.
JUST LOOKS LIKE, LIKE DRUGS.
MAYBE ONE OF THE MOST, THE BEST
PUBLIC HEALTH HUMAN FACTORS
DESIGN WAS MAKING AEDs REALLY
EASY FOR LAY PEOPLE TO USE.
THIS IS ALL HUMAN FACTORS IN
PLAY.
ON THE BOTTOM HOW WE DESIGN OUR
ENVIRONMENT MARY SHOWED ME THE
NEW HOLE IN THE GROUND IN THE
BUILDING GOING UP.
I HOPE THAT YOU HAVE A GOOD
HUMAN FACTORS ENGINEER ON YOUR
CONSULTANT TEAM TO REALLY DESIGN
THAT NEW SPACE SO IT WORKS.
SO, THIS IS THE SCIENCE BEHIND
HOW WE CAN MAKE OURSELVES
BETTER.
BUT WE'RE, AS WE SAID, WE'RE
HUMANS AND WE'RE GOING TO MAKE
MISTAKES.
SO HUMAN BEINGS BY THEIR VERY
NATURE MAKE MISTAKES.
EVERY HUMAN BEING, EVERY HOUR
MAKES UP TO FIVE MISTAKES OR
ERRORS EVERY HOUR.
WHEN YOU ARE STRESS THAT GOES UP
TO 12.
IT COULD BE JUST WALKING THE
WRONG WAY DOWN THE, YOU KNOW,
DOWN THE HALLWAY OR A
CATASTROPHIC ERROR.
SO NO ONE IS IMMUNE FROM THIS.
IT IS COMPLETELY UNREASONABLE WE
CAN MAKE HEALTHCARE THAT REALLY
COMPLEX ENVIRONMENT ERROR-FREE.
SO, PART OF UNDERSTANDING SAFETY
EVENTS IS UNDERSTANDING WHY WE
BEHAVE THE WAY WE DID.
SO I WANT TO TAKE YOU THROUGH
WHAT, THE DIFFERENT TYPES OF
ERRORS SO YOU GET A SENSE OF THE
KIND OF MISTAKES WE AS HUMANS
MAKE.
THEN YOU CAN ACTUALLY START TO
úCRE
BEHAVIOR AND ALSO THE SYSTEMS
ISSUES THAT WE'LL TALK ABOUT IN
A LITTLE WHILE.
SO THREE TYPES OF BEHAVIORISM
KNOWLEDGE-BASED, RULE-BASED, AND
SKILL-BASED.
WE CALL THEM ERRORS OF
AUTOAMTICITY.
SO KNOWLEDGE BASED, THESE ARE
AREAS THAT WE MAKE SIMPLY
BECAUSE WE DON'T KNOW SOMETHING.
WE DIDN'T HAVE THE TRAINING.
I DIDN'T TAKE THE CLASS.
I'M NOT KNOWLEDGEABLE.
SO, ONE EXAMPLE NONMEDICAL IS
EVERY TIME YOU GET INTO A NEW
RENTAL CARE, I, AT LEAST I
ALWAYS SIT THERE AND LOOK AT THE
WINDOW, YOU KNOW, THE WASHING
GAUGE, NOT HAVING ANY IDEA HOW
TO USE IT.
THERE IS NO STANDARDIZATION.
SOMETIMES IT IS TON THE RIGHT,
SOMETIMES IT IS ON THE LEFT, I
TURN ON MY BACKWASHER INSTEAD OF
THE FRONT WASHER OR TURN ON THE
LIGHTS OR MY, MY BLINKER.
THAT'S A KNOWLEDGE-BASE.
I DIDN'T TAKE THE TIME TO READ
THE MANUAL WHEN I GET IN THE
RENTAL CAR.
FROM A MEDICAL STANDPOINT, A NEW
INTERN PUTTING A CHEST TUBE IN
AND NOT HAVING AD "KNOWLEDGE TO
DO THAT.
SOMETHING WE CAN TEACH PEOPLE,
BUT WE HAVE TO UNDERSTAND IF
THERE IS A MISTAKE WHY THAT
PERSON DIDN'T GET THAT
INFORMATION.
RULE BASED ARE WHEN YOU APPLY,
YOU FOLLOW THE RULE, BUT YOU
JUST APPLY IT IN THE WRONG
SITUATION.
SO, ONE EXAMPLE IS I'M GOING TO
BOSTON IN JANUARY.
IT'S GOING TO BE COLD IN BOSTON,
BECAUSE IT IS ALWAYS COLD IN
BOSTON IN JANUARY.
SO I PACK A PARKA, BUT I GET TO
BOSTON IT IS 80 DEGREES.
RIGHT RULE, WRONG SITUATION.
I COULD HAVE CHECKED ACT TO
WEATHER, BUT I DIDN'T.
NOW, MEDICINE, YOU WALK INTO A
PATIENT'S ROOM THAT IS
UNRESPONSIVE, NO PULSE, NOT
BREATHING, YOU INITIATE CPR.
BUT THE PATIENT WAS A DNR.
RIGHT RULE, I SHOULD HAVE
RESUSCITATED THAT PERSON, BUT
THE WRONG SITUATION.
IN THOSE CASES YOU HAVE TO
UNDERSTAND WHY THEY APPLIED THE
RULE THE WRONG WAY.
WHAT DIDN'T THEY KNOW, THEY
DIDN'T HAVE INFORMATION ABOUT
THE PATIENT BEING A DNR WHY NOT,
NOT THE WRISTBAND ON OR IN THEIR
MEDICAL RECORD.
AND THE LAST ERRORS OF
AUTOMATICITY, SLIPS IN AND
LAPSE.
SO A SLIP IS WHEN YOU JUST MAKE
A MISTAKE.
YOU JUST DIDN'T DO WHAT YOU WERE
SUPPOSED TO DO.
SO ME GOING, MY BOWL OF CEREAL
IN FRONT OF ME IN THE MORNING,
GO TO THE REFRESHER AND PUT MILK
ON MY CEREAL, AND INSTEAD I GRAB
THE ORANGE JUICE AND POUR IT ON
MY CEREAL I DIDN'T TEEN TO DO
IT.
NO POLICY CHANGE IS GOING TO
KEEP ME FROM DOING THAT.
THOSE ARE THE FIRST TWO THINGS I
GO FOR.
SO, MAYBE I NEED TO PUT MY MILK
INSIDE OF THE REFRIGERATOR AND
MY ORANGE JUICE ON THE DOOR AND
GIVE ME A CUE.
IN MODESON IT IS PICKING UP THE
WRONG MEDICATION AS IT SITS
THERE.
LAMPSES ARE WHEN YOU FORGET A
STEP IN THE PROCESS.
HERE WE HAVE OUR SHERIFF WHO HAS
OBVIOUSLY GASSED UP HIS CAR OR
HER CAR AND THEN FORGOT THAT KEY
LAST STEP OF TAKING THE
BECAUSELING OUT OF THE CAR AND
PUTTING IT BACK IN THE PUMP.
HERE'S ONE, AN EXAMPLE WHERE --
A PHYSICIAN WAS ORDERING BLOOD.
THEY ORDERED THE RIGHT TYPE TO
THE RIGHT PERSON THE RIGHT TIME,
BUT THEY FORGOT THE LAST STEP OF
MAKING IT IRRITATED.
SO A LAPSE IS SIMPLY WHEN YOU
FORGET TO DO SOMETHING AND A
SLIP, YOU JUST, IT IS AN
AUTOMATIC, I DON'T KNOW WHY I
DID IT.
AND FINALLY VIOLATIONS.
THIS IS JUST WHEN SOMEBODY SORT
OF KNOWINGLY VIOLATES A RULE,
SPEEDING, MAYBE A NURSE MAKING
ALL OF HER MEDS AND PASSING THEM
AS ONCE OPPOSED TO DOING IT ONE
AT A TIME.
SO WHEN WE LOOK AT ERROR
CLASSIFICATION.
THERE IS INTENDED ACTIONS.
THAT'S THE KNOWLEDGE BASE AND
THE RULE BASED.
AND THEN UNINTENDED ACTIONS
THOSE ARE SKILL BASED OR HOOT
MUTICITY ERRORS THAT ARE SLIPS
AND LAPSE.
SO, WE WILL DO A QUIZ.
HERE IS THE FIRST CASE.
DURING THE PROCEDURE THE CRNA
NOTICED THAT THE PATIENT'S HEART
RATE AND BLOOD PRESSURE WERE
ELEVATED LEADING TO A CHECK OF
THE INFUSION PUMP.
THE INFUSION PUMP SHOWED THE
CRNA MISPROGRAMMED THE PUMP FOR
50 MICRO GRAMS, NOT
150 MICROGRAMS.
AND THE PATIENT NOTICED
AWARENESS FOR MINUTES OF THE
PROCEDURE.
WHICH ONE DO YOU THINK THIS IS,
KNOWLEDGE BASED, RULE BASED,
AUTOMATICITY, SLIP OR LAPSE.
IT IS A SLIP, SHE MISPROGRAMMED,
POURED THE ORANGE JUICE OUT
INSTEAD OF THE MILK.
NEXT ONE, PATIENT WAS TO RECEIVE
RADIATION TREATMENT FOR A LEFT
SHOULDER TUMOR, THE TECHNOLOGY
STARTED THE MACHINE TO SEE A
VERY AMBIGUOUS ERROR MESSAGE
THAT WE HAVE SEEN IN OUR OWN
PRACTICE.
THE TECHNOLOGIES ASSUMED THAT
THE DOSE WAS NOT DELIVERED WHEN
THE ERROR MESSAGE OCCURRED.
SHE TRIED, SHE RESET THE MACHINE
AND TRIED TWO MORE TIMES.
THE PATIENT RECEIVED THREE
DOSES, THREE TIMES THE DOSE OF
THE RADIATION.
SO, WHICH ONE IS THIS?
IT IS RULE-BASED.
BECAUSE SHE HAD A RULE THAT
WORKED FOR ANOTHER MACHINE.
BUT SHE JUST APPLIED IT TO THE
WRONG SITUATION.
SO, AGAIN, YOU KNOW, THAT WAS,
AN ERROR BY THE TECHNOLOGIST.
BUT WHY DID SHE ASSUME THAT.
HAD SHE BEEN, THERE WAS A NEW
MACHINE HAD PEOPLE NOT SHARED
WITH HER THAT THERE WAS THIS
DIFFERENCE?
SO, IT'S SORT OF IN BETWEEN
KNOWLEDGE AND RULE, BUT IT IS
REALLY A RULE-BASED ERROR.
THIS IS THE LOST ONE.
A PATIENT ACQUIRED A FINE NEEDLE
ASPIRATION OF THE THYROID,
ULTRASOUND REVEALED SIX
SUSPICIOUS NODULES, ASPIRATED
AND PREPARED ON THE SLIDE.
A NEW RULE WAS IMPLEMENTED.
AND THE ULTRASONOGRAPHY WAS NOT
GIVEN THE RULE.
SO THIS IS KNOWLEDGE BASED.
THEY DIDN'T KNOW ABOUT IT.
AGAIN, WE CAN RESTRAINT THAT
PERSON, WHY WAS THIS PERSON
ASKED TO DO THAT PERSON WITHOUT
THE TRAINING.
WAS IT THEY DIDN'T HAVE TIME?
OR SHORT-STAFFED SHE WAS THROWN
INTO THE SITUATION?
WE CAN ALWAYS LOOK AT WHY THE
PERSON DID WHAT THEY DID.
BUT THEY CAME TO WORK EVERY DAY
TO DO THE RIGHT THING.
WHAT WE NEED TO DO IS LEADERS IN
PATIENT SAFETY AND COLLEAGUES IS
TO TRY TO FIGURE OUT WHY THEY
ENDED UP DOING WHAT THEY DID.
SO, THE WHY STATEMENT IS
SOMETHING YOU'RE GOING TO HEAR
QUITE A WHILE.
WE CAN NOT ACCURATELY CHARACTER
ERRORS UNTIL WE UNDERSTAND WHY
THEY HAPPEN AND WE CANNOT
IMPLEMENT GREAT SOLUTIONS UNTIL
WE HAVE A DEEP UNDERSTANDING OF
WHY THEY HAPPENED.
AND BEFORE WE CAN UNDERSTAND WHY
THEY HAPPENED, WE HAVE TO KNOW
ABOUT THE EVENT.
WE ARE GOING TO TALK A LITTLE
BIT ABOUT EVENT REPORTING AND
THE REALLY, REALLY, IT IS REALLY
IMPORTANT TO REPORT EVENTS IN
AND ALL KINDS OF EVENTS.
OUR TAGLINES IS SECRETS CAN'T BE
FIXED.
AS HEALTHCARE PROVIDERS WE FIX
THE PROBLEM, PUT A PIECE OF DUCT
TAPE OVER IT AND MOVING ON.
AND THE NEXT PERSON PUTS A PIECE
OF DUCT TAPE OVER THE SAME
THING.
AND ONE OUT OF 10 DUCT TAPE
APPLICATIONS AND LEPT YOUR
SAFETY TEAM KNOW ABOUT THE ISSUE
AND WE CAN MAKE YOUR ENVIRONMENT
SAFER.
I'M GOING TO START ABOUT EVENT
REPORTING AND EVENT REVIEW,
THOUGH, TALKING ABOUT
PSYCHOLOGICAL SAFETY.
SO, PSYCHOLOGICAL SAFETY IS A
TERM THAT AMY EMENSON IS A
THOUGHT LEADER IN THIS WORLD
COINED.
THE SHARED BELIEF AMONG TEAM
MEMBERS THAT THE TEAM IS SAFE
FOR RISKTAKING.
SO AMY STARTED HER TEAM UP WITH
DAVID BITES, THE DOC WITH THE
ARTICLE A FEW MINUTES AGO, HE
WANTED TO STUDY THE REPORTED
MEDICATION ERRORS ON A COUPLE OF
PATIENT UNITS IN THE HARVARD
HOSPITAL.
AND AMY IS A SOCIAL RESEARCHER
AND INTERESTED IN TEAM DYNAMICS
AND PSYCHOLOGICAL SAFETY.
HER HYPOTHESIS WAS THAT TEAMS
THAT HAD REALLY BAD
PSYCHOLOGICAL SAFETY AND DIDN'T
WORK WELL TOGETHER WOULD
ACTUALLY HAVE WAY MORE ERROR
REPORTS BECAUSE THEY JUST
WEREN'T WORKING WELL TOGETHER.
WELL, IT WAS ACTUALLY THE
OPPOSITE.
WHAT THEY FOUND WAS
HIGH-PERFORMING PSYCHOLOGICALLY
SAFE TEAMS HAD HIGHER RATE OF
REPORTING BECAUSE PEOPLE FELT
SAFE TO DO IT.
WE'RE ENCOURAGED TO DO IT.
AND WHEN THEY WERE REPORTED,
THINGS WERE DONE ABILITY THOSE
REPORTS AND THE, ENVIRONMENT,
THE CARE ENVIRONMENT WAS
IMPROVED.
SO PSYCHOLOGICAL SAFETY IS SO
IMPORTANT.
NOT ONLY FOR SPEAKING UP AND
GETTING PEOPLE TO SPEAK UP, BUT
IT IS REALLY IMPORTANT TO GIVE
PEOPLE ACROSS OUR ORGANIZATION
AGENCY TO HELP INVENTOR.
BECAUSE WHEN WE'RE TRYING TO FIX
THINGS, WE DON'T WANT THE PEOPLE
WITH MANY LETTERS BEHIND THEIR
NAMES AND ALL OF THE WINDOWS IN
THEIR OFFICES MAKING DECISIONS
ABOUT WHAT HAPPENS AT THE
BEDSIDE.
WE WANT THE FRONT LINE STAFF
DOING THAT.
IT'S REALLY HARD IF YOU ARE A
FRONT LINE STAFF AND YOU WALK
INTO A ROOM AND THERE'S A LOT OF
WHITE COATS AND A LOT OF LETTERS
AND A LOT OF WINDOWS SITTING
THERE NEXT TO YOU.
WE HAVE TO MAKE IT SAFE FOR
PEOPLE TO DO THAT.
SO WHAT DO WE WANT FOLKS TO
REPORT?
EVERYTHING.
I KNOW PEOPLE TEND TO JUST
REPORT THINGS THAT HURT
PATIENTS, BUT THAT DOESN'T HELP
US IMPROVE.
THAT MAKES US IMPROVE ABOUT THAT
ONE THING, BUT DOESN'T GIVE US A
CHANCE TO IMPROVE PERSPECTIVELY.
WE WANT YOU TO TALK ABOUT AND
REPORT UNSAFE CONDITIONS.
NEAR MISSES, THOSE ARE ERRORS
THAT OCCURRED BUT NEVER QUITE
REACHED THE PATIENT, EITHER
BECAUSE WE WERE REALLY GOOD AND
CAUGHT IT OR JUST DARN LUCKY.
SO A LOT OF PEOPLE CELEBRATE
NEAR MISSES.
WE ACTUALLY, WE ACTUALLY TAKE A
PAUSE AND SAY, OKAY, WERE WE
GOOD OR LUCKY AND THEN WE
CELEBRATE.
SO REALLY UNDERSTANDING THOSE
NEAR MISSES AND PRECURSORS AND
UNSAFE CONDITIONS WILL MOVE THE
DIAL INNING TERMS OF SAFETY.
AND PROCESS ISSUES, THE SILLY
LITTLE THINGS THAT KEEP YOU FROM
DOING THE WORK YOU NEED TO DO IN
AN EFFICIENT AND EXPENSIVE WAY.
TAKE TIME TO PUT THOSE INTO
STARS.
PEOPLE WANT TO HEAR ABOUT THOSE.
SORRY.
WHOOPS.
GOT A LIFE OF ITS OWN.
OKAY.
AND THEN, OF COURSE, ERRORS AND
GOOD CATCHES.
YOU KNOW, HEALTHCARE IS TOUGH
RIGHT NOW.
LET'S SEPBRAILLE ONE ANOTHER.
SO IF SOMEONE IS DOING REALLY
GOOD STUFF, LET'S CELEBRATE
THAT.
BUT REALLY THAT BLUE BOX AT THE
BOTTOM IS TAKE AWAY FOR THIS
SLIDE.
EVENTS DON'T HAVE TO REACH OR
IMPACT YOUR PATIENTS TO BE
REPORTABLE.
WE WANT TO KNOW WHEN YOU AS
HEALTHCARE PROVIDERS JUST HAD A
BAD FEELING ABOUT A SITUATION
BECAUSE YOU KNOW THAT THE NEXT
TIME IT COULD ACTUALLY RESULT IN
HARM.
SO I ALSO WANT YOU TO THING
ABOUT MORE THAN PHYSICAL HARM.
BECAUSE WE THINK ABOUT PHYSICAL
HARM A LOT.
BUT THERE IS EMOTIONAL HARM.
THERE IS EMOTIONAL HARM TO A
PATIENT THAT HAS BEEN INJURED.
A HUGE AMOUNT OF EMOTIONAL HARM
TO A PROVIDER WHO CAUSES HARM.
THERE IS INTER GENERATIONAL
HARM.
I WORK WITH A LOT OF FAMILIES
WHO HAVE LOST CHILDREN AS A
RESULT OF HARM FROM ALL OVER THE
UNITED STATES.
THAT NEXT CHILD OR THE OLDER
CHILD, THEY HAVE A REALLY HARD
TIME, THERE'S A VERY HIGH RATE
OF DEPRESSION AND SUICIDE
AMONGEST KIDS THAT ARE, FAMILY
MEMBERS WHERE THEY LOST A CHILD
TO, A MEDICAL ERROR.
AND THEN FINANCIAL HARM.
AND MEAN, WE DON'T REALLY SEE
OUR PATIENTS AFTER THEY LEAVE.
I DON'T KNOW IF THE MAN WE MADE
NOT BE ABLE TO WALK IS ABLE TO
KEEP -- AN INCOME COMING IN AND
TAKING CARE OF HIS FAMILY.
SO YOU KNOW, THE BURDEN'S GREAT.
OF US JUST THINKING ABOUT
PHYSICAL HARM.
BUT WE NEED TO EXPAND THAT AND
THINK ABOUT THE OTHER TYPES OF
HARM.
OKAY.
SO, WE KNOW ABOUT THESE EVENTS.
SO NOW, WE HAVE TO DO SOMETHING
ABOUT IT.
WE HAVE TO DO THE RIGHT THING
BECAUSE IF WE DON'T, IT CAN
REALLY KILL SCULPTURE.
WE NEED TO FIND THE WAYS, WHY
DID IT HAPPEN, NOT WHO IS
RESPONSIBLE, BUT WHY DID IT
HAPPEN?
WE TALKED ABOUT HOW SOMEBODY
MAKES AN ERROR.
I SAID IT IS ALL OF THOSE LITTLE
DOTS AND SYSTEMS PIECES THAT
ACTUALLY CONSPIRED TO PUT THAT
HEALTHCARE PROVIDER IN THE
SITUATION WHERE THEY ENDED UP
CAUSING HARM.
SO THIS IS FROM, WE GET TO WORK
WITH THIS GREAT GUY, A DOC
CALLED ED TORRE, AN EXPERT ON
INFLUENCE, HE SAID THIS AT ONE
OF OUR SESSIONS, I HAD TO SHARE
IT WITH FOLKS, THE SINGLE MOST
IMPORTANT IMPACT ON SAFETY
CULTURE IS HOW WE RESPOND TO
EVENTS.
IF WE IGNORE IT IS BAD.
DO IT THE WRONG WAY IT IS BAD.
IF WE BLAME PEOPLE INVOLVED THAT
IS REALLY BAD.
BAD FOR THE PERSON, BAD FOR US,
BAD FOR THE PATIENT.
THIS IS HOW WE DO IT AT MEDSTAR
HEALTH.
THE CLINICAL CENTER HAS A
STRUCTURED WAY TO DO IT, TOO.
SO HOW TO LOOK AT THE STRUCTURED
PATIENT SAFETY EVALUATIONS IS
REALLY IMPORTANT.
BECAUSE YOU NEED TO HAVE A
ROADMAP TO FOLLOW.
SO IT'S THE IMMEDIATE RESPONSE,
YOU GET IN THERE, YOU START
MAKING SURE THE PATIENT'S OKAY.
HOW IS THAT CAREGIVER DOING?
DO THEY NEED TO BE PULLED OUT.
TALK ABOUT CARE FOR THE
CAREGIVER.
YOU WANT TO ENGAGE WITH THE
PATIENT AND FAMILY AND SAY,
LOOK, I DON'T KNOW WHAT
HAPPENED.
WE ARE REALLY SORRY.
SOMETHING HAPPENED HERE.
WE'RE GOING TO LOOK INTO IT.
WE WILL KEEP YOU IN THE LOOP.
JUST MAKE SURE THAT EVERYBODY'S
ENGAGED.
AND THEN THE REALLY HARD WORK
COMES IN THE IN-DEPTH EVENT
REVIEW.
WHERE YOU'RE DOING INTERVIEWS,
TAKING OBSERVATIONS, DOING A LOT
OF ANALYSIS, PEER REVIEW COMES
IN HERE, YOU'RE LOOKING AT AN
INDIVIDUAL PROCEDURE MAYBE,
M&Ms, AND GATHER THE
INFORMATION, AND THEN WE DO A
LEARNING TEAM, WE GET EVERYBODY
INVOLVED IN THAT PROCESS
TOGETHER.
YOU KNOW, YOU LEARN A LOT IN ALL
OF THE INTERVIEWS, BUT JUST ONE
PERSON'S PERSPECTIVE.
NOW, WE HAVE TO LUXURY OF
GETTING TOGETHER IN THE LEARNING
TEAM, EVERYBODY GETS TO HEAR
EACH OTHER'S PERSPECTIVE AND
CONFIRM AND VERIFY, AND I DON'T
KNOW HOW IT WAS, SURGEON, THIS
IS HOW I WAS THINKING FROM A
SURGICAL TECH PERSPECTIVE.
BUT THE REAL BEAUTY, WE GET
PEOPLE TO DO SOLUTION
DEVELOPMENT, GETTING PEOPLE AT
THE FRONT LINE COMING UP HOW TO
DO IT.
WE WILL TALK ABOUT THE CONCEPT
OF WORK ISMAGEAGED VERSUS WORK
IS PREFORMED.
THE CENTRAL PART OF AN EVENT
REVIEW IS WHY.
THIS IS BASICALLY GETTING TO THE
WHY.
USING A SYSTEMS LENS AND TRYING
TO UNDERSTAND WHY IT HAPPEN AND
GOING THROUGH AND IDENTIFYING
WHAT ARE CALLED CONTRIBUTING
FACTORS.
WE USE THE BUCKETS RELIGIOUSLY.
COMMUNICATION, INFORMATION, WHAT
IS GOING ON THERE.
WE WILL GO INTO THESE IN DETAIL,
HUMAN FACTORS AND INFLUENCES.
POLICY AND PROCEDURES.
THE HUMAN BEINGS ININVOLVED AND
HOW THEY WERE TRAINED AND
WHETHER THEY ARE COMPETENT, AND
LEADERSHIP AND CULTURE, AND THEN
TECHNOLOGY AND THE ENVIRONMENT.
SO, COMMUNICATION INFORMATION
MANAGEMENT.
NUMBER ONE CAUSE OF ROOT CAUSES.
WE ALSO, YOU CAN ALSO CALL THIS
PROCESS ROOT CAUSE ANALYSIS.
WE USE IT AT MEDSTAR HEALTH, BUT
IT IS ESSENTIALLY A ROOT CALL
ANALYSIS.
SO, NUMBER ONE EVENTS WHEN THEY
DID ROOT CAUSE ANALYSIS FOR THE
JOINT COMMISSION IS
COMMUNICATION.
DO YOU HAVE ACCESS TO ALL OF THE
AVAILABLE INFORMATION THAT YOU
NEED?
IS YOUR EHR PROVIDE YOU WITH THE
INFORMATION IN A TIMELY AND
ACCURATE WAY?
HOW ARE PEOPLE COMMUNICATING
AMONGST THEMSELVES?
HOW ARE HANDOFFS HANDLED?
IS THERE A BIG HIERARCHY WHERE
BETWEEN MAYBE TRAINEES AND THEIR
ATTENDINGS OR NURSING
SUPERVISORS AND THE CLINICAL
RESEARCH NURSES?
THEN YOU WANT TO LOOK AT HUMAN
FACTORS.
WE JUST TALKED ABOUT HUMAN
FACTORS AND ALL OF THOSE
INFLUENCES.
HOW WE INTERACT WITH OUR
ENVIRONMENT, EQUIPMENT,
USABILITY, THINGS THAT HAPPEN TO
US AS HUMANS, STRESS, FATIGUE.
ALL OF THE COGNITIVE BIAS WE
TAKE TO DIAGNOSES, CONFIRMATION
BIAS, ANCHORING BIAS, AND THEN
OUR PATIENTS BRING A LOT TO THIS
WHOLE PICTURE.
BECAUSE DEPENDING ON THEIR
ACUITY, THEIR ENGAGEMENT, THEY
REALLY CAN PLAY A PART IN THEIR
SAFETY AS WELL.
POLICIES AND PROCEDURES.
DID WE HAVE THEM IN PLACE?
DO PEOPLE ACTUALLY PAY ATTENTION
TO THEM?
IT THERE A CULTURE THAT WE JUST
DON'T ADHERE TO THEM, IT IS HOW
WE HAVE ALWAYS DONE IT, I DON'T
CARE WHAT THE POLICY ACTUALLY
SAYS.
WHAT IS THE CULTURE AROUND THAT?
THIS BRINGS INTO THIS WORLD THIS
CONCEPT OF WORK IS IMAGINED
VERSUS WORK IS PERFORMED.
ONE WAS MY GUIDING PRINCIPLES.
SO, YOU KNOW, WORK IS IMAGINED
IS ALL THAT WONDERFUL WORK THAT
WE DO THAT IS SO WELL-DESIGNED
AND IT IS ALL SCIENCE-BASED AND
EVIDENCE-BASED WHICH IS ALL
WONDERFUL.
WHETHER YOU'RE DOING A CLINICAL
RESEARCH PROTOCOL AND DESIGNING
A RESEARCH PROTOCOL OR A
CLINICAL PRACTICE GUIDELINE OR
SOP FOR SOMETHING, YOU KNOW,
TYPICALLY OFTENTIMES REALLY
SMART PEOPLE GET IN A ROOM AND
DESIGN THIS WONDERFUL PROCESS,
YOU CAN SEE IN THIS CARTOON,
A-TO-B, EASY-PEASY, SEND IT OUT
THERE, EVERYONE WILL DO IT THE
SAME WAY.
BUT THE SMARTEST PERSON IN THIS
ROOM ACTUALLY OPENED THE DOOR
AND SAW THE PASTA BOWL THAT IS
HEALTHCARE OUTSIDE OF THAT DOOR
AND SAID, THERE'S NO WAY THIS
POLICY IS GOING TO HAPPEN LIKE
THAT AT 3:00 IN THE MORNING IN A
CRAZY ICU WHERE WE ONLY HAVE,
YOU KNOW, THREE NURSES AND 12
PATIENTS.
SO, THAT'S WORK IS IMAGINED.
AND WORK IS DONE.
AND WE NEED TO NOT HAVE A HUGE
GAP THERE.
THIS IS ONE OF THE BIGGEST
DOWNFALLS IN HEALTHCARE RIGHT
NOW IS THAT WE ARE, WE DESIGN
THINGS AS WE THINK THEY SHOULD
HAPPEN, BUT THEY CAN NEVER BE
IMPLEMENTED IN THE REAL WORLD.
I REALLY ENCOURAGE YOU TO GO
BACK TO YOUR SPACES AND THINK
ABOUT PLACES WHERE THIS HAPPENS.
IT IS A FASCINATING EXERCISE.
OKAY, HUMAN RESOURCES, TRAINING
AND COMPETENCY.
DO WE HAVE THE RIGHT PEOPLE ON
THE BUS DOING THE RIGHT WORK.
AND TRAINING PEOPLE, AND
ACTUALLY KNOW THEY ARE DOING THE
WORK WELL THAT WHY TRAINED THEM
TO DO.
DO WE HAVE GOOD SUMMER VISION?
OR TRAINEES AND FOLKS OUT THERE
DOING WHAT THEY WANT TO DO.
IN 2024 STAFFING, AT LEAST OUT
IN THE WORLD WHERE I LIVE, IS
REALLY TOUGH.
WE MAY HAVE ENOUGH HUMANS AT THE
BEDSIDE, BUT THOSE NURSES AND
PHARMACISTS AND RESPIRATORY
THEORISTS, SOME OF THEM ARE
STRAIGHT OUT OF SCHOOL.
AND REMEMBER, A LOT OF THEM WERE
TRAINED DURING COVID.
SO THEY GOT VERY LITTLE CLINICAL
WORK.
AND IT CAN BE REALLY SCARY ON A
NIGHT SHIFT IN A REALLY BUSY
WARD WHERE WE HAVE REALLY
INEXPERIENCED FOLKS.
WE DON'T HAVE THAT MUSCLE
MEMORY.
SO SOMETHING STARTS TO HAPPEN, A
CODE IN THE MIDDLE OF THE NIGHT,
NOBODY ON THAT FLOOR MANAGED A
CODE.
I THINK WE HAVE TO START
THINKING ABOUT THAT IN TERMS OF
SAFETY AS WELL.
LEADERSHIP AND CULTURE.
THIS IS THE HEARTEDDEST ONE.
BASICALLY HOW WELL DO WE DO WITH
SAFETY CULTURE.
DO WE HAVE A KNOWLEDGE PUNITIVE
ENVIRONMENT WHEN PEOPLE WANT TO
TALK ABOUT SAFETY.
WHAT IS THE INFLUENCE OF
HIERARCHY.
WE WILL TALK ABOUT HEALTH EQUITY
AND THINGS LIKE THAT.
AND THEN, TECHNOLOGY AND
EQUIPMENT.
DO WE HAVE THE TECHNOLOGY WE
NEED THIS IS IT UP DATE?
AND DONE THE PREVENTIVE AND
USABILITY.
AND FINALLY THE PHYSICAL
ENVIRONMENT, WITH OUR NEW SPACE
ARE WE ACTUALLY DESIGNING THAT
SPACE FOR SAFETY?
OR ARE WE DESIGNING IT IT FOR
THE CONVENIENCE OF THE HUMANS
DOING RESEARCH PROTOCOLS.
IT IS A BIT OF A TENSION
SOMETIMES.
SO, I'M GOING TO JUST TAKE YOU
THROUGH A CASE.
YOU CAN SEE THE IMPORTANCE OF
FIGURING OUT THE CONTRIBUTING
FACTORS.
AND A NURSE ADMINISTERED A
FIVEFOLD DOSE OF CHEMOTHERAPY.
WHEN THEY LOOKED INTO IT, THE
NURLS DIDN'T USE MEDICATION
BARCODE SCANNING AND DIDN'T DO
AN INDEPENDENT DOUBLE CHECK THAT
YOU NEED TO DO WITH A HIGH ALERT
MEDICATION.
SO IN SOME ORGANIZATIONS, A
PERFORMANCE IMPROVEMENT PLAN, OR
REORGANIZATION HER, OR FIRE HER,
DEPENDING ON THE ORGANIZATION,
BECAUSE WE'RE TRYING TO BE HIGH
RELIABILITY, AND SENSITIVE TO
OPERATIONS, WE ASK THE SERIAL
WHYS.
WHEN THEY DID THAT IT IS A
DIFFERENT PICTURE.
THE WI-FI IS UNRELIABLE.
HALF OF THE TIME MY SCANNER
DIDN'T WORK.
WHAT IS THE USE OF TAKING IT.
BY THE WAY, THEY ARE MISSING,
LOST, OR THE DARNEL NIGHT NURSES
DIDN'T PUT THEM ON THE DOCKING
STATION, SO THERE IS NO CHARGE
AT 8:00 MEDS.
THERE IS NO ADVANTAGE OR
INCENTIVE TO USE IT.
THE SENIOR FOLKS WERE NOT USING
IT FOR THE ABOVE REASONS.
THIS IS A NEW NURSE, SHE DIDN'T
GET A LOT OF TRAINING IN IT.
THAT SORT OF PAINTS A DIFFERENT
PICTURE.
WHAT ABOUT INDEPENDENT DOUBLE
CHECKS?
THIS NURSE HAD FOUR OTHER HIGH
ACUITY PATIENTS, SOMEONE COMES
BACK FROM AN EXTENSIVE
PROCEDURE.
THERE IS A LOT GOING ON FOR HER
TO GET INTO THAT ROOM.
AND OH, BY THE WAY, THE PATIENT
WAS ON ISOLATION, AND DAWN
ON-AND-OFF PPE WHEN SHE WENT IN
THERE.
I DON'T KNOW IF YOU HAVE TAKEN
CARE OF AN ISOLATION PATIENT,
AND ASKING A FELLOW NURSE TO DO
AN INDEPENDENT DOUBLE CHECK.
THEY SCATTER.
ANYBODY CAN HELP ME, BUT THERE
IS NOBODY ON THE UNIT.
SHE COULDN'T REAL ON A REGULAR
BASIS, BE CERTAIN THERE WAS
SOMEONE TO HELP US.
THIS WAS NOT A BAD NURSE.
THIS IS BAD LEADERSHIP.
BAD SYSTEM.
WHAT WE HAVE DONE IS SUCK THIS
POOR NURSE UP TO DO NOT HER BEST
WORK.
WHICH SHE CAME TO WORK TO DO
EVERY DAY.
YOU THINK ABOUT THOSE
CONTRIBUTING FACTORS IT HITS
ALMOST EVERY ONE OF THESE.
IF YOU DIDN'T TAKE THE TIME TO
BE VERY DELIBERATE IN DOING
THIS, YOU WOULD MISS THE MARK.
YOU DON'T HAVE TO DO THIS IN THE
CONTEXT OF A FORMAL ROOT CAUSE
ANALYSIS.
SOMETHING COMES UP IN YOUR
ENVIRONMENT, PULL THIS PIECE OF
PAPER OUT AND SAY, OKAY, WERE
THERE COMMUNICATION ISSUES?
AND THE POLICY CONFUSING?
WAS THE ENVIRONMENT WEIRD?
YOU CAN DO THIS IN THE CONTEXT
OF A CLINICAL EVENT.
YOU HAVE A DEVIATION OR A SAE,
IS IT SAE, DID I PULL THAT OUT
OF MY BRAIN?
OKAY.
IN THE CONTEXT OF A RESEARCH
PROJECT, YOU CAN USE THIS SAME
METHODOLOGY TO MAKE SURE THAT
YOU'RE JUST NOT POINTING FINGER
IN THE WRONG DIRECTION.
WHEN THERE SHOULD BE NO FINGER
POINTING AT ALL.
WE'RE STARTING TO EMBED EQUITY
INQUIRY INTO OUR EVENT REVIEWS.
SO IF WE ASK ABOUT
COMMUNICATION, WE THINK ABOUT
COMMUNICATION ISSUES, MAYBE
WE'RE ASKING AND LOOKING INTO
LITERACY LEVEL.
WAS THERE A LITERACY ISSUES THAT
COULD HAVE BEEN IN PLAY FOR A
PATIENT.
MAYBE THEY DIDN'T UNDERSTAND THE
INFORMATION WE GAVE AND THERE
FORE, THEY DIDN'T TAKE THEIR
MEDICATION AND HAD AN EVENT.
OR PSYCHOLOGICAL SAFETY IN THE
TEAM TO ESCALATE ISSUE TO IT
PERSON WITH THE MANY LETTERS
BEHIND THEIR NAMES.
FROM A POLICIES AND PROCEDURES,
ARE WE STILL USING CLINICAL
ALGORITHMS THAT USE RACE AS A
BIOLOGICAL KAJ STRUCK LIKE
KIDNEY FUNCTION, WE NEED TO GET
THOSE OUT OR OUR PLAYBOOK.
LEADERSHIP AND CULTURE, LOOK AT
MODELING.
PHYSICAL ENVIRONMENT AND
EQUIPMENT, ADA COMPLIANT, THINGS
LIKE TEMPORAL THERMOMETERS AND
SKIN TONE, ALL OF THESE THINGS
COME INTO PLAY, WE REALLY NEED
TO LOOK AT THEM.
HUMAN RESOURCES, WHAT'S THE
DIVERSITY OF OUR CARE TEACH LOOK
LIKE?
A PLACE WHERE EVERYBODY FEELS
SAFE AND COMFORTABLE WITHIN
THEIR TEAMS?
AND THEN FINALLY, WITH HUMAN
FACTORS AND INFLUENCES, THOSE
IMPLICIT BIASES IT IS ABOUT RACE
AND ETHNICITY OR LANGUAGE OR
SUBSTANCE ABUSE, MENTAL HEALTH
ISSUES.
SO WE'RE STARTING TO LOOK AT HOW
EQUITY ISSUES HAVE A PLAY IN
THE -- CAUSE OF SAFETY EVENT,
BUT ALSO MAYBE HOW WE'RE
RESPONDING AS WELL.
OKAY.
WE HAVE TAKEN A LOOK BACK AT
WHEN AN EVENT OCCURS.
WE KNOW A LITTLE BIT ABOUT THE
SCIENCE BEHIND HOW TO KEEP THEM
FROM HAPPENING IN THE FUTURE.
BUT WE WANT TO GO IN HEALTHCARE
IS REALLY NOT HAVING ANY HARM AT
ALL.
WHICH MEANS WE HAVE TO START
LOOKING FOR RISKS BEFORE IT EVEN
HAPPENS.
WHICH WE DON'T HAVE TIME IN OUR
LIVES TO LOOK INTO BAD THINGS
THAT HAPPEN, BUT WE NEED TO
START CARVING OUT TIME TO DO
THIS PROACTIVE AND PERSPECTIVE
RISK ASSESSMENT.
SO, THIS IS A FRAMEWORK THAT WE
USE.
IT'S SORT OF A CONTINUUM OF
REACTIVE TO PROACTIVE.
WE LIVE IN THIS, FOR HEALTHCARE
IN GENERAL, FOR THE MOST PART,
LIVE IN SORT OF TERTIARY AREA,
ON THE RIGHT-HAND SIDE.
VERY REACTIVE.
WE HAVE GOTTEN GOOD AT
IDENTIFYING EVENTS.
WE HAVE GOTTEN PRETTY GOOD AT
ANALYZING EVENTS.
AND WE'RE PRETTY GOOD AT
DEVELOPING SOLUTIONS.
NOT AS GOOD AS SHARING THE
SOLUTIONS AND WHAT WE DID TO FIX
THINGS.
BUT WE'RE PRETTY COMFORTABLE
THERE.
BUT THINGS ARE STILL HAPPENING.
HARM IS STILL HAPPENING.
THE DATA SHOWS US THAT.
SO WHAT WE WANT TO DO IS MOVE
FURTHER TO THE LEFT HERE AND
BECOME MORE AND MORE PROACTIVE.
WE'RE GETTING GOOD AT
IDENTIFYING PROBLEMS AND
MITIGATING EXISTING RISKS.
WE KNOW THIS IS GOING TO HAPPEN,
LET'S PUT IN PLACE A STOPPING
THIS FROM HAPPENING, BUT WE WANT
TO DESIGN SAFETY INTO NEW
PROCESSES.
SO THE MINUTE WE DECIDE WE HAVE
AN IDEA ABOUT A NEW PROCESS WE
WANT TO PUT IN OR BUILDING WE
WANT TO BUILD, WE IMMEDIATELY
START DESIGNING SAFETY INTO IT
AND IDENTIFYING RISKS BEFORE
SOMETHING HAPPENS.
WE'RE GOING TO TALK A LITTLE BIT
ABOUT HOW YOU DO THAT.
YOU CAN DO THIS -- RISKS
ASSOCIATED WITH CLINICAL CARE,
BUT WE ALSO DO IT WITH RISKS
ASSOCIATED WITH CLINICAL
RESEARCH.
AND THESE ARE COUPLE EXAMPLES OF
WHERE WE USED A PROACTIVE RISK
ASSESSMENT OR ANOTHER NAME IS A
FAILURE MODES AND EFFECTS
ANALYSIS TO LOOK FOR RISKS IN
NEW PROCEDURES, IN THIS CASE, A
COUPLE OF PROTOCOLS, BEFORE THEY
WERE EVER LAUNCHED.
YOU CAN SEE TARA THERE IN HER
GRAB, EBOLA GARB.
DID A LOT OF WORK WITH HES
TRYING TO FIGURE OUT WHERE BAD
THINGS CAN HAPPEN, WITH MICHELLE
EVANS, WHERE BAD THINGS CAN
HAPPEN BRINGS THE PATIENTS INTO
THE REALLY COMPLEX ENVIRONMENT.
WE INTRODUCED A PROTOCOL.
WHERE WERE CREWS HEPATIC
INFUSIONS ARTERIAL PUMPS.
THEY WITHER NOT USED HERE
BEFORE.
AND WE ARE THE CLINICAL CENTER.
WE CAN PRETTY MUCH DO ANYTHING.
IT IS GOOD TO TAKE A PAUSE, WE
FOUND A COUPLE OF THINGS WE
COULD PROBABLY IMPROVE ON.
AND DID WORK AROUND NIMH AROUND
THE NEUROBIOLOGY OF SUICIDE.
THIS TOOL IS REALLY, REALLY
USEFUL IN THE CONTEXT OF
CLINICAL RESEARCH.
SO A PROACTIVE RISK ASSESSMENT
OR FMEA.
IS A SYSTEMATIC ANALYSIS OF A
PROCESS IN ORDER TO IDENTIFY ALL
OF THE BAD THINGS THAT CAN
HAPPEN WITH IT.
ARE SO IF YOU HAVE A LITTLE BIT
OF INNER EEYORE, YOU KNOW THE
CHARACTER IN WINNIE THE POOH
THAT THINKS THE WORLD IS ALL
GRAY AND THE GLASS HALF FULL,
YOU GET TO SIGN, YOUR JOB IS TO
COME IN AND TELL ALL OF YOUR
COLLEAGUES HOW BAD THEIR IDEA
WAS SO WE CAN FIND ALL OF THE
THINGS WE NEED TO FIX BEFORE IT
GOES LIVE.
THE REASON YOU WANT TO DO THAT.
YOU HAVE THE LUXURY OF THEN
ELIMINATING OR MINIMIZING THAT
RISK OR IF THAT RISK IS STILL
GOING TO BE THERE, AND SOMETIMES
WE HAVE TO ACCEPT THE RISK,
CERTAINLY IN THIS ENVIRONMENT,
WE'RE DOING PROOF OF PRINCIPLE
STUDIES, YOU ACCEPT A LOT OF
RISK, BUT YOU NEED TO BUILD
RESILIENCY INTO IT.
IF THERE IS A RISK OUT THERE,
WHAT ARE WE GOING TO DO IF THAT
HAPPENS, AND IDENTIFY IT EARLIER
BEFORE IT BECOMES CATASTROPHIC.
THESE ARE COME EXAMPLES OF WHERE
WE USED THIS PROACTIVE PAUSE AT
MEDSTAR HEALTH IN THE LAST YEAR
AND A HALF OR SO.
AGAIN, THE GOAL IS JUST TO FIND
BAD THINGS THAT HAPPEN BEFORE
THEY ACTUALLY HAPPEN.
SO EVERYTHING FROM LOOKING AT
NEW TELEMETRY AND RESPIRATORY
MONITORING EQUIPMENT TO OUR
HELICOPTER GUYS AND LADIES AND
MEN, AND WANTED TO USE, PUT MORE
ECMO AND BYPASS EQUIPMENTS ONTO
A SMALLER HELICOPTER.
AND WE REALIZED THAT IF THEY DID
THAT, NOBODY WOULD BE ABLE TO
GET TO THE PATIENT.
THEY TRASHED THAT IDEAS AND
STARTED AGAIN.
VIRTUAL NURSING.
I DON'T KNOW IF THE NURSING
DEPARTMENT IS THINKING ABOUT
VIRTUAL NURSING.
THAT RAISED MY BLOOD PRESSURE A
LOT.
WE ARE LOOKING INTO THAT.
WE HAVE AN IMRI, MRI IN THE
NEW -- OPERATING ROOMS IN THE
STANDING PAVILION.
AND HAVING GONE, HAVING BEEN
INVOLVED IN PUTTING THAT MRI IN
THIS SPACE, WHEN THEY STARTED TO
TALK ABOUT IT I GOT VERY
INTERESTED.
AND SO WE DID A PRESCRIPTIVE
RISK ASSESSMENT THERE.
AND THEY HAD DONE A PRETTY,
REALLY GOOD JOB OF SORT OF
DESIGNING THE MRI STUFF AROUND,
THE MRI PROCESSES, BUT THE STUFF
AROUND IT, THE SCHEDULING, WHAT
OTHER PEOPLE'S ROLES ARE, THEY
DIDN'T PAY A LOT OF ATTENTION TO
THAT.
WE FOUND WHAT THEY COULD FINISH
SO THEY DIDN'T RUN INTO
PROBLEMS.
REALLY USEFUL TOOL.
SO JUST WANT TO TAKE YOU THROUGH
HOW TO DO IT.
AGAIN, THIS DOESN'T HAVE TO BE
REAL FORMALISM YOU CAN DO THIS
ON A PATIENT CARE UNIT SITTING
IN YOUR LAB JUST THINKING ABOUT
A NEW PROCESS YOU WANT TO
DESIGN.
FIRST OUT LINE THE STEPS OF THE
PROCESS, SO EVERYBODY AGREES
WHAT IS GOING TO HAP.
.
NOW IS THE TIME TO BRING OUT THE
INNER EAR OR -- OR -- EEYORE.
AND WHICH ARE THE RISKIEST TO
FIX.
SOME PEOPLE USE A HAZARD SCORE.
WE USE A PROCESS CALLED MY THREE
BIGGEST WORRIES.
WE HAVE PEOPLE LOOK AT ALL OF
THE FAILURE MOLDS AND PICK OUT
THE ONES THEY ARE WORRIED ABOUT,
AND THOSE WE FOCUS ON.
THE PEOPLE IN THE ROOM ARE THE
PEOPLE THAT DO IT EVERY DAY.
IT WOULD BE VERY DIFFERENT IT WE
HAD PROGRAM DIRECTORS, CEO, THE
HEAD OF NIH SITTING IN A ROOM
TRYING TO FIGURE OUT HOW TO DO A
NURSE PROCEDURE.
BUT WHEN YOU HAVE BEDSIDE NURSES
THERE, YOU FEEL CONFIDENT WHERE
THE BAD THINGS LIE.
I WANT TO TAKE YOU THROUGH.
THIS IS WORK YOUR SAFETY
SPECIALIST IN THIS BUILDING
WORKED ON SEVERAL YEARS AGO.
A NIMH STUDY, YOU WILL SEE A
THEME.
NIMH HAS BEEN A GOOD PARTNER
AROUND PATIENT SAFETY IN THIS
WORLD.
THIS IS A STUDY LOOKING AT
DOPAMINE ON SELF-CONTROL AND
IMPULSIVENESS.
TO THERE ARE PEOPLE ENGAGED IN
SUBSTANCE ABUSED.
THEY LIVED IN BALTIMORE CITY.
AND MANY OF THEM LIVED IN A
SHELTER, AND LIKELY TO LIVE IN A
SHELTER OR ABOUT HOWSED.
AND THE PROTOCOL REQUIREMENTS
WERE INTERESTED, THEY NEEDED TO
GET HERE EARLY.
PET SCANNING AT THE TIME OF THIS
WAS VERY DIFFICULT TO GET.
YOU HAD A VERY NARROW WINDOW OF
GETTING THAT PATIENT HERE, DRUG
TESTED, THE PET SCAN, GIVING
THEM INFUSION, AND MRI.
SO TIGHTLY COUPLED IF YOU MISSED
IT BY 15 MINUTES YOU BLEW THE
WHOLE DAY.
THAT SCANNING SLIDE.
SO IT JUST -- SWEEP ELEMENTARY
SCREAMED RISK TO US.
BETWEEN THE PATIENT POPULATION,
THE TIGHT COUPLING AND THE
IMAGING REQUIREMENTS.
WE DID AGFMEA.
REALLY GOOD PARTNERS ON THE
RESEARCH SIDE AND CLINICAL SIDE.
WE FLOWCHARTED OUT THE PROCESS.
BASIC, HIGH LEVEL, GET TO THE
CLINICAL CENTER, GO TO THE
CLINICAL, GET THE MED, THE PET
SCAN, THE IMAGING.
SO LOOKING AT THREE OF THOSE
PROCESS STEPS ABOUT WHAT COULD
GO WRONG.
SO ARRIVING THAT CLINICAL
CENTER.
WE'RE GETTING PEOPLE WHO HAVE
CHALLENGES JUST ON A DAY-TO-DAY
BASIS LIVING, READY AT 6:00 IN
THE MORNING TO GET TO A TAXI TO
TAKE THEM TO THE CLINICAL CENTER
AND GET THROUGH SECURITY.
JUST THAT IN ITSELF IS DANCING.
THEN YOU ADD IN THINGS LIKE TAXI
DELAY.
THIS IS BEFORE UBER WAS A BIG
THING.
AND THEN TRAFFIC DECAYS.
AGAIN, IT DOESN'T SEEM ON THE
SURFACE THAT'S A TERRIBLY BAD
THING, BUT IT BLOWS THAT WHOLE
VISIT IF THEY ARE LATE.
AND THEN MEDICATION
ADMINISTRATION.
YOU KNOW, IT IS TIME IN THE PAST
WHERE THERE WERE, YOU KNOW,
PHARMACY WAS GOING THROUGH
CHANGES.
SO, MEDICATION DELAYS AND THINGS
LIKE THAT WERE NOT UNCOMMON.
AND SO, MAKING SURE THAT WE GOT
MEDICATIONS UP TO THAT SPACE AT
VERY EARLY HOURS, LIKE 7:00 IN
THE MORNING WAS CHALLENGING.
SIMPLY BECAUSE OF STAFFING.
NOT ANYBODY'S FAULTS.
IT WAS JUST HOW THE SYSTEM WAS
DESIGNED AT THE TIME.
MAKING SURE THAT WE HAVE THE
RIGHT EQUIPMENT.
SOMETIMES THE EQUIPMENT WENT
MISSING.
ALONG THINGS, BUT A NURSE AND
GET THERE AT 7:00 IN THE MORNING
AND SOMEONE HAS TAKEN YOUR
MONITORING EQUIPMENT AND YOU
HAVE TO FIND IT AND GOT THIS
TIGHT COUPLING IT THROWS AVENUE
INTO CHAOS.
AND THE PET SCAN, TRASHERSE WAS
HARD TO GET AT SOMETIMES, AND
WHAT IF THERE WAS A CLINICAL
EMERGENCY.
HAVE YOU EVER THOUGHT ABOUT
HAVING TO MANAGE, YOU KNOW, AND
PRACTICE AND DRILLED AN
EMERGENCY IN THE PET SCANNING
AREA?
SO, THOSE WERE ALL THINGS THAT
WERE CONSIDERED.
AND THEN, JUST -- SOLUTIONS WERE
DEVELOPED BASED ON EACH OF THESE
FAILURE MOLDS TO TRY TO REDUCE
THE RISKS.
SOME OF THE THINGS WE'RE
IMPLEMENTED AND WORKED REALLY
WELL.
ORALLY THINGS THE TEAM CHOOSE
NOT TO IMPLEMENT.
WE IDENTIFIED THAT THEY PROBABLY
NEEDED TO IMPLEMENT IT BECAUSE
DELAYS OCCURRED.
JUST AN EXAMPLE ABOUT HOW YOU
CAN APPLY THIS TO A CLINICAL
RESEARCH PROTOCOL AND ANY ONE OF
THE OTHER CLINICAL AREAS THAT I
MENTIONED TO YOU BEFORE.
SO JUST -- WE SPEND A LOT OF
TIME TALKING ABOUT DOING
REACTIVE WORK.
AND RCAs AND LOOKING AT
EVENTS.
I REALLY ENCOURAGE YOU, WE'RE ON
THIS JOURNEY, TOO, AT MEDSTAR
HEALTH, TO REALLY THINK
PROACTIVELY ABOUT THINGS,
BECAUSE IT WILL MAKE OUR
PATIENTS SAFER.
SO A COUPLE OF KEY TAKEAWAYS.
GROUND YOUR WORK IN SAFETY
SCIENCE.
AND HUMAN FACTORS.
IT'S REALLY A LIFE CHANGER.
A GAME-CHANGER.
ALL OF THE SUDDEN YOU ARE DRIVEN
BY SCIENCE, THERE IS NO PLACE
BETTER THAN THIS TO BE DRIVEN BY
SCIENCE.
SPEAK UP, REPORT HAZARDS AND
HARM.
REPORT HAZARDS AND HARM, REPORT
HAZARDS BECAUSE YOU GOT TO KNOW
THE NEAR MISSES.
USE THAT SYSTEM'S LENS TO ALWAYS
ASK WHY.
AND REALLY LEAN INTO THE
CONTRIBUTOR FACTORS.
NANOT JUST IN THE CONTEXT OF A
ROOT CAUSE ANALYSIS, BUT
UNDERSTANDING WHAT IS GOING ON
WITH SOMETHING GOING ON THERE IN
YOUR LAB OR IN YOUR, ON YOUR
PATIENT CARE UNIT.
AND BE ALSO BE ON THE LOOK OUT
FOR RISKS AND POTENTIAL RISKS
THAT ARE OUT THERE.
AND I'LL LEAVE YOU WITH YOUR
WEEKEND READING LIST.
THIS IS SORT OF WHAT YOU CAN
LOOK AT TO LEARN MORE ABOUT THE
WORK THAT, THE INFORMATION THAT
I TALKED ABOUT.
BUT MOSTLY, I WANT TO THANK YOU
ALLLER FOR INVITING ME.
THIS IS A REALLY SPECIAL
EXPERIENCE, IT IS SO GOOD TO SEE
EVERYBODY.
AND JUST AWESOME.
I'M HAPPY TO TAKE ANY QUESTIONS.
[ APPLAUSE ]
OH, YEAH.
>> HI, LAURA LEELER HOW ARE YOU.
>> ONE VERY NICE PRESENTATION.
I REALLY THINK THAT EMPHASIZING
THE PROACTIVE IS THE WAY TO GO
BECAUSE ONE OF MY CONCERNS IS
WITH THIS REACTIVE MODE WE'RE
IN, THERE'S A LOT OF HEAT AND
MOTION THAT'S BEING MISTAKEN FOR
ACTUAL CORRECTION OF THE ACTUAL
PROBLEMS.
YOU KNOW, THERE'S -- A HUGE
CHURN AND PEOPLE WHO ARE NUMBER
VOLVED IN THAT CHURN IN REACTING
TO ALL OF THESE THINGS, THERE'S
OFTEN AN UNDERSTANDING, BUT
ITY NOT A COMMITMENT TO
PUTTING IN THE PROPER
ENGINEERING CONTROLS AND SO
FORTH WHICH ACTUALLY TAKE A LOT,
TAKE A LOT OF RESOURCES.
EVERYONE'S TRYING TO FIX THINGS
WITH THE RESOURCES THEY HAVE.
AND THE UNDERSTANDING THAT THEY
HAVE.
SO THE PEOPLE WHO ARE ANALYZING
IT, YOU KNOW, WHEN YOU DO
MENTION, IT IS IMPORTANT TO HAVE
THE NURSES WHO ARE ON THE THE
FLOOR IN THAT ROOM.
BUT I CAN TELL YOU, YOU ASK A
BUNCH OF SAY RADIOLOGISTS WHAT
THEY WANT IN A PAC SYSTEM THEY
DON'T ACTUALLY KNOW.
THEY KNOW WHAT THEY'VE DONE AND
WHAT MAKES THEM EFFICIENT, BUT
IF SOMEONE, YOU KNOW, BREAKS
OUT-OF-THE-BOX TO MAKE IT MUCH
EASIER, THEY'RE NOT NECESSARILY
TO PEOPLE WHO IMAGINE THAT.
I'M SURE IF YOU ASKED A BUNCH OF
RADIOLOGIST 50 YEARS AGO TO GET
RID OF FILM, NO IT NEVER WOULD
HAVE HAPPENED.
THE ONLY HAPPENED, THERE WAS NO
STUDIES, THIS IS NOT FROM
SCIENTIFIC RESEARCH, THAT SAYS
IT IS BETTER TO DO THIS.
SO HOW YOU APPLY THESE
TECHNOLOGIES, BUT I THINK IT IS
REALLY IMPORTANT TO GET THERE.
AND THE -- AND THE COMMITMENT
TO -- TO DO THESE PROACTIVE
THINGS, BECAUSE, I CAN THINK
OF -- IT'S HARD TO KNOW.
SO WHERE'S THE FEEDBACK.
YOU FIXU SOMETHING, NO ONE KNOS
YOU FIXED IT BECAUSE IT IS
FIXED.
YOU DON'T GET CREDIT FOR IT.
NO ONE KNOWS.
IT IS REALLY HARD TO GET THAT TO
WORK.
SO I'M JUST THROWING THINGS OUT,
BUT HOW WE GET FROM THE REACTIVE
PRO ACTIVE, I THINK IT IS REAL
CHALLENGE.
>> LAURA: YEAH, IT'S REALLY
HARD.
WE ARE NOT ANYWHERE NEAR IT YET.
FOR, EXACTLY WHAT YOU SAID IT IS
LIKE WE FIXED IT, NOTHING
HAPPENED.
SO THEREFORE, WE WERE RIGHT ALL
ALONG SORT OF THING.
SO, I THINK IT STARTS WITH
LEADERSHIP, CULTURE REALLY
EMBRACING PROACTIVE AND STARTING
TO TALK ABOUT IT AND HELPING
PEOPLE UNDERSTAND WHAT IT IS.
THEN JUST DO A COUPLE OF GOOD
EXAMPLES.
SO, THIS IS BEFORE I WANT TO
MEDSTAR HEALTH, THEY WERE HAVING
A BUNCH OF PROBLEMS WITH CORD
CUP APPROXIMATIONS.
PATIENTS WERE COMING INTO THE ED
AND IT WAS MISSED.
FOR 30 YEARS I WAS SHELTERED
FROM FRO S WORLD OF THESE
CATASTROPHIC EFFERVENTS THAT
HAPPEN AND ALSO FROM THE WORLD
THAT CLAIMS COME IN THAT YOU PAY
APPROPRIATELY, BECAUSE WE HARMED
SOMEBODY, BUT THEY HAVE A REAL,
MEDSTAR HEALTH HAVE VERY
FINANCIALLY STABLE, BUT IT HAS
AN IMPACT ON WHAT YOU CAN DO.
MEDSTAR HEALTH IS VERY, VERY
PROACTIVE IN TRYING TO ADDRESS
THOSE SORTS OF THINGS.
SO CORD COMPRESSION.
SO, A BUNCH OF CASES.
INSTEAD OF JUST LOOKING AT THE
CASES THAT HAPPENED,EY HTH
STARTED TO DO, THEY WENT BACK
AND LOOKED AT ALL OF THE CASES
THAT WERE CORD COMPRESSION
CASES, BUT NEVER ENID UP BEING A
BAD EVENT, THEY CAME IN AND GOT
TREATED IMMEDIATELY.
THEY LOOKED AT THOSE AND FIGURED
OUT WHAT HAPPENED, WHO WAS DOING
IT WELL.
WERE, WHAT WERE THEY DOING WELL
THAT THE OTHER PEOPLE WEREN'T.
IT HAD TO DO WITH AVAILABILITY
OF RESOURCES IN TERMS OF IMAGING
AND COMMUNICATION.
SO, YOU KNOW, YOU JUST, IT IS
JUST A DIFFERENT MIND-SET.
WE HAVE GOTTEN GOOD AT LOOKING
AT EVENTS.
BUT MAN, IT TAKES LOT MORE WORK.
SO IT IS LOT MORE WORK TO GO AND
LOOK AT 50 CASES OF THINGS THAT
WENT WELL THEN THREE CASES THAT
WENT POORLY.
SO YEAH.
IT IS JUST A CULTURE CHANGE.
>> HI, LAURA.
FIRST OF ALL, THANK YOU,NK BUT I
WANTED TO ASK IF YOU CAN COMMENT
ON THE FACT THAT THIS IS A GRAND
ROUND FOR THE GRADUATE MEDICAL
EDUCATION PROGRAMS.
ARE WE REALLY DON'T ALWAYS THINK
ABOUT WHERE TRAINEES, PHYSICIAN
TRAINEES IN PARTICULAR, FIT INTO
THE SYSTEM AND WHETHER THEY
UTILIZE THESE REPORTING SYSTEMS
AND WHAT'S YOUR ADVICE IS AND
HOW YOU CAN HELP US ENCOURAGE
THAT MORE AMONG THE PHYSICIANS
HERE.
>> LAURA: THANKS.
THAT IS REALLY TRUE.
REPORTING SHOULD HAPPEN ACROSS
THE BOARD.
FIRST OF ALL THEY NEED TO KNOW,
FIRST OF ALL IT HAS TO BE
MODELED WITH THE LEADERSHIP THAT
REPORTING IS IMPORTANT.
SO STARTING THAT THE LOCAL
LEVEL.
THEY HAVE TO KNOW HOW TO REPORT.
AND THEY NEED TO KNOW SORT OF
WHAT TO REPORT.
SO THAT NEEDS TO BE DONE AT THE
PROGRAM LEVEL.
NEEDS TO BE MODELED.
AND IF PEOPLE PUT REPORTS IN
THEY SHOULD TALK ABOUT IT AT
THEIR HUDDLES OR MEETINGS.
AT THE ORGANIZATIONAL LEVEL,
THIS HAPPENS ACROSS HEALTHCARE.
WE FOR NOT REALLY GOOD AT
FEEDING BACK WHAT WE DID.
SO FOLKS THAT ARE SAFETY LEADERS
NEED TO FIGURE OUT WAYS TO GET
THE INFORMATION THAT PEOPLE HAVE
TAKEN PRECIOUS MOMENTS OF THEIR
TIME TO TELL US ABOUT, HOW DO
YOU FEED THAT BACK.
THAT IS REALLY ONE OF THE KEY
WAYS TO GET IT TO CHANGE.
BUT I THINK JUST ENCOURAGING
FOLKS TO ENTER THINGS.
YOU HAVE TO HAVE THAT
PSYCHOLOGICAL SAFETY.
WE STILL SEE INSTANCES WHERE
PEOPLE ARE NOT PUTTING THINGS IN
BECAUSE MAYBE THEY ARE NOT BEING
ENCOURAGED TO DO IT.
OR THERE IS A NONPUNITIVE
RESPONSE.
THAT'S ACROSS HEALTHCARE IN GEN.
SO YEP.
>> I WAS WONDERING TO WHAT
EXTENT YOU HAVE SEEN PEOPLE USE
OR YOU SEEN IF THERE MIGHT BE
ANY POTENTIAL FOR USING MORE
TOOLS OF PROCESS ENGINEERING
LIKE MARKOV CHAIN MODELING OR
COMPLEXITY SCIENCE, LIKE AGENT
BASED MODELING TO SORT OF
UNDERSTAND PATIENTW AND, YOU
KNOW, ANTICIPATE PROBLEMS BEFORE
THEY ARISE AND MOVE LIKE, YOU
KNOW, THE HEURISTICS REALLY
IMPORTANT, BUT SORT OF HOW YOU
MIGHT INTERFACE WITH THAT.
>> LAURA: YEAH.
SO I WILL PROBABLY JUST NOT
ANSWER A LOT, BECAUSE I KNOW
ABOUT ENOUGH TO KEEP, TO GET
MYSELF IN TROUBLE BY ANSWERING
YOUR QUESTION.
I AM VERY FORTUNATE TO WORK IN
AN ORGANIZATION THAT HAS A WHOLE
CENTER ON HUMAN FACTORS
ENGINEERING.
AND THEY HAVE A HUGE GROUP THAT
ARE LOOKING AT THAT.
BUT I THINK THOSE ARE ALL PARTS
OF THE SCIENCE THAT WE NEED TO
BE PUTTING IN PLACE.
IT IS JUST THAT WE NEED --
HEALTHCARE TO FIND SPACE AND
MONEY TO DO THAT.
THAT'S REALLY THE PROBLEM.
SO YES.
THERE ALL IMPORTANT.
AND THEY ALL NEED TO BE DONE.
BUT HEALTHCARE IS OPERATING IN A
1% MARGE RECALL GENERALLY, THERE
IS NOT A LOT OF ROOM OUT IN THE
REAL WORLD TO BE ABLE TO USE
THOSE THINGS RIGHT NOW.
YES, THAT'S WHERE WE WANT TO GO.
AND HOPEFULLY, SOMEDAY WE WILL
GET THERE.
>> THANK YOU FOR SUCH A
WONDSCUSSION TODAY.
REGARDING OUR TOPIC ON THE
SHIFTING THE SAFETY FROM
REACTIVE TO PROACTIVE, I THINK
ONE OF THE KEY FACTORS THAT YOU
WERE JUST DISCUSSING IS THIS
CONCEPT OF PSYCHOLOGICAL SAFETY.
AS THE LEADER OF A CLINICAL
TEAM, WHAT'S THE -- BEST INITIAL
APPROACH TO ADDRESSING
PSYCHOLOGICAL SAFETY?
IS THERE A GOLD STANDARD?
IS THIS TRAINING SEMINAR?
AN OPEN DISCUSSION?
OR IS THIS A SYSTEMATIC THING?
CULTURAL WITHIN THE HOSPITAL?
WHAT'S THE BEST WAY TO ADDRESS
IT?
>> LAURA: ALL OF THE ABOVE.
THIS IS A WHOLE, THIS IS ANOTHER
HOUR LONG TALK THAT I CAN GIVE
YOU.
SO IT, IT STARTS -- IT JUST
STARTS WITH THE LEADER BEING
OPEN LEADER.
WANTING TO KNOW WHAT IS GOING
ON.
ASKING PEOPLE'S OPINION,
ENGAGING PEOPLE, MAKING SURE
THAT PEOPLE FEEL COMFORTABLE
BRINGING THEIR IDEAS IF SOMEONE
COMES TO YOU WITH AN IDEA, TALK
TO THEM ABOUT IT IF IT IS AN
IDEA THEY CAN'T USE OR RESOURCE
IT, TELL THEM WHY.
MAKING SURE THAT EVERYBODY FEELS
COMFORTABLE.
THERE IS NO SORT OF
MICROAGGRESSIONS WITHIN THE
GROUP.
IT IS A BIG LEADERSHIP
MANAGEMENT -- CHALLENGE BECAUSE
YOU HAVE TO BE OUT THERE
CONSTANTLY, CONSTANTLY
CULTIVATING.
SO THERE IS TRAINING AROUND IT.
BUT IT HONESTLY, IT IS MOSTLY
LEADERSHIP MODELING.
WE DO TRAINING WITH OUR LEADERS
AROUND PSYCHOLOGICAL SAFETY AND
HOW TO GET THERE, WHAT IT IS,
WHAT IT ISN'T.
WE GOT, I CAN SEND THAT TO
JOYCE, I'VE GOT JUST A
POWERPOINT SLIDE THAT HAS EIGHT
THINGS THAT YOU CAN DO AS A
LEADER.
ONE OR ALL EIGHT OF THEM EVERY
DAY TO START TO BUILD THAT
PSYCHOLOGICAL SAFETY.
I THINK ONE THING THAT HAS
HELPED US TALKING T ABOUT
THE CONCEPT OF PSYCHOLOGICAL
SAFETYONCE
YOU START TO SOCIALIZE IT,
THEN PEOPLE START TO EXPECT IT
AND HOLD YOU AS A TEAM LEADER
ACCOUNTABLE FOR IT.
BUT JUST MAKING SURE THAT
EVERYBODY IS INCLUDED IN WHAT'S
GOING ON.
AND THAT PEOPLE DON'T GET SHAPED
AND BLAMED AND BULLIED.
IT IS REALLY PRETTY BASIC STUFF,
BUT SO ESSENTIAL.
I'M HAPPY TO TALKABOUT
IT ANY TIME, I'M PASSIONATE
ABOUT THAT TOPIC IN PARTICULAR.
>> THANK YOU.
>> LAURA: THANK YOU.