A novel approach to patient safety

Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
O
I
Using
healthcare
simulation to
explore resilience:
A novel approach
to patient
safety
P
RHCN 2014
O
O
Emergency in the Operating Room
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
RHCN
2014
Healthcare Simulation can be used to
understand and improve
1
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
The technical and non-technical
skills of individuals
RHCN
2014
1
Individual skills
Intubation
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
RHCN
2014
Healthcare Simulation can be used to
understand and improve
1
The technical and non-technical
skills of individuals
2
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
The technical and non-technical
skills of teams
RHCN
2014
2
Teamwork skills
Manage the
trauma team
as well as the
patient
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
RHCN
2014
Healthcare Simulation can be used to
understand and improve
1
The technical and non-technical
skills of individuals
2
The technical and non-technical
skills of teams
The characteristics of
Systems
3
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
Local/Micro
Department
Committee
Organization
Care cycle
Work flow
RHCN
2014
3
Systems
Iterative
improvement of
post-partum
hemorrhage
protocols and
processes
Test and refine
before
implementing
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
RHCN
2014
Healthcare Simulation
Regular/
Irregular
threat
?manikin
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
Need
Simulator
Scenario /
“story”
Simulation
Learning
Debrief
RHCN
2014
Low technology
Image from Laerdal™
High technology
Full sized, human manikins
• Breathe,
chest wall motion
• Palpable pulses
• Reactive pupils
• Respond to
interventions
• Vital signs
displayed
on monitor
in real time
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
RHCN
2014
Biologic tissue
Living or Non-living
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
RHCN
2014
Virtual
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
Images:
• Courtesy of Greg Wiet
• https://www.youtube.com/watch?v=C
7wDMeqa3Ss accessed 8/1/14
• Simbionix.com
RHCN
2014
Human!
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
RHCN
2014
Debriefing
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
RHCN
2014
In situ systems practice:
fire in the operating room
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
RHCN
2014
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
RHCN
2014
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
RHCN
2014
Make it Real!
• Real Teams
• Real Equipment
• Real Setting
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
Video edited by Brian Pio
RHCN
2014
Resilience: A Texas perspective
“There’s rules to riding a horse
But the horse won’t necessarily know ‘em”
--Texas Bix Bender
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
RHCN
2014
Simulation can replicate
any part of a system
Develop
condition
Thrive!
Obtain consult
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
undergo surgery
Recover
RHCN
2014
Patient Care “Quarterback”
Press MJ. N Engl J Med 2014;371:489-491.
Simulation Practices And Goals
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
In theory there's no difference
between theory and practice.
In practice there is."
-Yogi Berra
RHCN
2014
• Incidents provide
indication of adaptive
capacity and changes
in adaptive capacity
• Simulation provides
means to evaluate this
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
Woods and Cook, Resilience Engineering:
concepts and precepts 2006 p69
RHCN
2014
25
Habituation
• Don’t notice that which goes
smoothly, nor do we think it is
necessary to do so.
• Neither is there any
motivation to try to understand
why things went well
• Because nothing bad
happened.
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
Hollnagel, A tale of Two Safeties, 2012
http://jimtjr.blogspot.com/
RHCN
2014
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
Bridging sciences in Resilience Engineering
research and training. MINES ParisTech
accueille le "Deans Forum, 2nd workshop
on Resilience Engineering"
RHCN
2014
Monitoring
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
RHCN
2014
Responding
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
RHCN
2014
Responding
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
RHCN
2014
Requisite Imagination
• Ability to anticipate when and
how calamity might strike
– Learn from experience
– Processing “faint signals”symptomatic events,
suspected trends, gut
feelings and intelligent
speculation
• Columbia shuttle disaster
• Simulation?
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
Westrum, Resilience Engineering Concepts and
Precepts. 2006, p59
RHCN
2014
Learning
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
RHCN
2014
Types of Threats
• Situation 1: regular threat
– Occurs often enough to
develop a standard
response
• Situation 2: irregular threat
– Apollo 13: entirely
unexpected but not
impossible or
unimaginable
– Tests organization’s ability
to self-organize and
respond to event
(improvisation)
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
Remaining Sensitive to the Possibility of Failure, 2008 &
Westrum, Resilience Engineering: Concepts and Precepts,2006
p 57
RHCN
2014
Anticipating
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
RHCN
2014
• Situation 3: the
unexampled event
– 9/11
– Tsunami: Southeast
Asia 2009
• Requires shift in
mental framework
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
RHCN
2014
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
Lanir: http://www.articlesbase.com/economicsarticles/fundamental-surprise-israeli-lessons-2784076.html
RHCN
2014
Work as Simulated
brings us closer to Work as Done
Work as
Imagined
Work as Done
Big Data:
Work as
Abstracted
Patterson, MD
Deutsch, MD
Fairbanks, MD
Jacobson, MD
Wears, MD
PhD
Work as Simulated
RHCN
2014