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Lessons from Aviation and Surgery
- 1. Painfull Transparancy Martijn Kriens 14 November 2013
- 2. Martijn Kriens ! Medical Data Recorder ! Research ! Quality Assurance ! Pilot ! @martijnkriens, martijn.kriens@icrowds.net
- 3. Human Fallibility! ! Systemic learning! ! Surgical education
- 4. Human Fallibility Truth emerges more readily from error than from confusion ! Francis Bacon
- 5. TO ERR IS HUMAN
- 6. TO BE HUMAN IS TO ERR
- 7. 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)!
- 10. Surgery is responsible for 60% of all Avoidable Errors (22.500) Direct costs are > 125M euro per year 1,6% 2004 2008 2012 1,2% 0,8% 0,4% 0,0% Diagnose Surgical Treatment Medication Care Release Others Monitor Zorggerelateerde Schade 2008, NIVEL
- 11. Systemic learning I am always ready to learn although I do not always like to be taught ! Winston Churchill
- 14. 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
- 15. 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!
- 16. Lesson Tenerife 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
- 19. Plan the proces - checklists, … Act on deviations - analise and adapt Do accoording to agreed processes Check expected outcomes with reality
- 20. Surgical education Improvement begins with I ! Arnold Glasow
- 21. Failures due to communication errors (60 out of 258) Not Transmitted 49% Misunderstanding 44% Not Received 7% Patterns of Communication Breakdowns Resulting in Injury to Surgical Patients, Greenberg, 2007
- 23. More than 50% of operation reports do not describe what really happened
- 25. High reliability organisations Preoccupation with failure! • Anticipation • – Challenge beliefs, don’t stop asking why ? ? ? Sensitivity to operations! • • Contaiment Actively find failures and learn Reluctance to simplify! • Succes Failure 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-tohardwire-each-in-your-organization.html?goback=%2Egde_4877284_member_240196966
- 26. Lessons for surgery • Collective memory! • Shared • stories Evidence based processes! • organizational • © Medical Data Recorder quality Team focus! • Hierarchy • An error does not imply guilt
- 27. 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)!
- 28. Medical Data Recorder Facts do not cease to exist because they are ignored. ! Aldous Huxley
- 29. Data from sensors Tagging activities Vision and sound
- 31. Core issues implementation in hospital Independent and safe! • No connection to EPD • No data to IGZ • Secure storage • Only used for independent research • Integrated and objective! • Indisputable data • Integration of data streams in the timeline • Only to be used for organisational learning! • No Blame • No obsolete data •