making sense of system- based safety · making sense of system-based safety angela gibbs, inland...
TRANSCRIPT
Making Sense of System-Based Safety
Angela Gibbs, Inland Hospital
Madeline Orange, Maine Sentinel Event Team
Joe Katchick, Maine Sentinel Event Team
Jeff Brown, Maine Primary Care Association Patient Safety Organization
USM Patient Safety Academy
September 29, 2017
1.A System Model
2.Accidents as decision side effects
3.Just culture
4.A case for your review
A system model: people are a system component
Institute of Medicine. (2011) Health IT and Patient Safety: Building Safer Systems for Better Care. Pages 59-75. Accessed January 22, 2013. http://www.iom.edu/Reports/2011/Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Care.aspx.
Patient Experience
Front-line units
Healthcare
Organization
C
BA
Payors
A System of Systems: Nested Levels of the U.S.
Healthcare System
D
Legislation…Clinical Space
Berwick, D., A User’s Manual for the IOM’s ‘Quality Chasm’ Report, http://www.healthaffairs.org; Corrigan, et al., 2001
Accidents as Decision Side Effects
Judith’s story: Morphine Misadventures
BCMA Meets Cost Pressure
Patankar, Brown, Treadwell, 2005
The U.S. Healthcare System’sCascade of Decision Side-effects
C
A
B
D
Clinical Space
A
BCost Cutting
Focus on Efficiency
C
Payments
Tort Law
Legislation…
D
Clinical Space
The U.S. Healthcare System’sCascade of Decision Side-effects
Slips
Lapses
Mistakes...Fragmentationof care processes.
Understaffing
Time Pressure
Fatigue
A
B
Cost Cutting
Focus on Efficiency
C
Payments
Tort Law
Legislation…
D
Clinical Space
11
The U.S. Healthcare System’sCascade of Decision Side-effects
Slips
Lapses
Mistakes...Fragmentationof care processes.
Adverse EventUnderstaffing
Time Pressure
Fatigue
A
B
Cost Cutting
Focus on Efficiency
C
Payments
Tort Law
Legislation…
D
Clinical Space
The U.S. Healthcare System’sCascade of Decision Side-effects
Slips
Lapses
Mistakes...Normalizedrisk; unsafe behavior
Heightened
potential for an
adverse event
Time pressure,
nominal workflow
interrupted,
unworkable
procedure,
inadequate #
scanners..
A
B
New facility planned
Cost cutting
Focus on efficiency
C
Payments
Tort Law
Legislation…
D
Clinical Space
Judith’s Story
Organizational Learning, Forgetting and The Functioning of
Frontline Units Over Time
Reliability
Efficiency
Bankruptcy
Adverse Outcome
Balance
Latent Conditions
Latent Conditions
Latent Conditions
Adapted from Managing the Risk of Organizational Accidents, J. Reason, 1997
Dampening the Accident See-SawSensitive Surveillance, CSE Investigation, and Corrective Action
Reliability
Efficiency
Bankruptcy
Adverse Outcome
Balance
Latent Conditions
Latent Conditions
Latent Conditions
Adapted from Managing the Risk of Organizational Accidents, J. Reason, 1997
Changes in clinical
resources, tasks,
processes, tools…
Goal conflicts,
Constraints…
Adaptations,
Workarounds,
Normalized
risk..
Near
misses
Injury
or
Death
A Safety Management SystemContinual Surveillance: Detection, Identification, Corrective Response, Monitoring for Effect
Reactive
Feedback
Loops
Proactive
feedback loops
CorrectionAccelerated
Org. Response
Early Identification and Management of Emergent Risk and Hazard in Clinical Space
1. Detection via Risk Triggers, Team Debriefing and Feedback, Safety Reports…
2. Clinically situated investigation using the socio technical system lens (CSE methods)
3. Development of corrective action using investigative findings
4. Monitoring for intended and unintended effects
5. Ongoing surveillance, problem detection, and rapid cycle improvement
The “system of interest” for the improvement of patient safety is defined not by the business affiliations of providers, but by patient pathways within and among provider facilities, and by the information exchange that attends that patients’ care.