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• Veiliger &
efficiënter The Medical Data Recorder
Martijn Kriens
Martijn.kriens@medarec.com

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Schade in het ziekenhuis
Zorggerelateerde schade in 8%
(↑) van alle opnames/jaar:
• 1/3 potentieel vermijdbaar
• 10.000 pat/jr: potentieel vermijdbaar
blijvend letstel
• 50% van alle potentieel vermijdbare
schade: zorgverlener gerelateerd
• Snijdende specialismen: 62% alle
zorggerelateerde schade, waarvan de helft
binnen de chirurgie
• Chirurgie: 40% (↑) alle potentieel vermijdbare
schade
Monitor zorggerelateerde schade 2008
Professor Cordula Wagner

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Two orders of magnitude (100x)
Safete in aviation and hospital

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• Sensitive to processes
– Transparancy, ratio’s
• No search for simple explanations
– Challenge beliefs
• Preoccupation with failure
– Where does it work better
• Expertise instead of hierarchy
– Open channels
• Resilience
– Clear why
High reliability organisations
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

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• Sensitive to processes
– Focus on individual skills …
• No search for simple explanations
– This is how we do it
• Preoccupation with failure
– Forget failures, move on
• Expertise instead of hierarchy
– The surgeon knows best
• Resilience
– Tradition
Medical professionals (negative view …)

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Back to the basics
Aviation
safety
Quality
Assurance
Patient
safety
Checklists
Procedures
Training syllabi
communication

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Foundation of quality improvement

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CRM and MDR
Do
Act CRM
MDR
Assurance in
processes
Improvement of
processes

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• Focus on learnings instead of guilt
– Just Culture
• Quality of organisation over individual
– Organisational learning, Crew Resource
Management
• Objective data and analysis
– Medical Data Recorder
Foundation

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• To be human is to err …
• “Safe” incident reporting
• Systemic errors
• Learning, not prosecution
• Gross negligence remains punishable
– Honest mistakes not
Just culture
punitive blame free
safety

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Organisational learning
Operation
Physician
Crew Resource
management
Individual
learning
Organisational
learning
Medical
Data
Recorder

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Objective analysis
• Humans have bad memory under pressure
– More than 50% operation report are wrong
• Multiple perspectives
– Anesthesiologist, nurse, surgeon, ..

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Change of culture
From Individual Hero’s
to a
Learning Organisation

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Integrated analysis
Vision
and
sound
Data
from
sensors
Tagging activities

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Voet
Operatietafel
Kop
CARRÉCONSTRUCTIE
C4
C1
C2
C3
BP
Anesthesie
1
Anesthesie
2
BP BP
C
1-­‐4:
camera’s
1
t/m
4
BP:
extra
bevestigingspunt
BP
Time-­‐out
/
Briefing

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• 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
Core issues implementation in hospital

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Questions?
Martijn Kriens
Martijn.kriens@medarec.com