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SUSP Implementation:Learning From Defects 1
Learning From Defects Through Sensemaking
Dr. Brad Winters, MDCUSP FOR SAFE SURGERY:
SURGICAL UNIT-BASED SAFETY PROGRAM (SUSP)
Implementation Phase
SUSP Implementation:Learning From Defects 2
Quick AdministrativeAnnouncements
• Dial into the conference line:• Dial in Number: 1-800-311-9401
• Passcode: 120816
• Webinar URL: https://connect.johnshopkins.edu/project_susp/
• Contact your Coordinating Entity for these slides• Recording of this webinar available at • Interact with us today
• Type comments in the chat box
• Or even better, speak up
SUSP Implementation:Learning From Defects 3
Polling Question
What is your role in your clinical area?– Surgeon– Quality Improvement practitioner– Infection preventionist– OR nurse– OR technician– Anesthesiologist– OR manager– Educator– Coordinating Entity– Other
SUSP Implementation:Learning From Defects 4
Polling Question
Have you established your SUSP team?– Yes– No
SUSP Implementation:Learning From Defects 5
Polling Question
Has your SUSP team started meeting regularly?– Yes– No
SUSP Implementation:Learning From Defects 6
Polling Question
• Where are you from?• Enter organization in the chat box.
SUSP Implementation:Learning From Defects 7
Learning Objectives
• Describe difference between first-order and second-order problem solving
• List contributing factors that make defects in care more likely to occur
• Use the Learning For Defects (LFD) tool to perform second-order problem solving
SUSP Implementation:Learning From Defects 8
C U S P F O R S A F E S U R G E R Y
1. Educate staff on the science of safety
2. Identify defects
3. Partner with a senior executive
4. Learn from defects
5. Improve teamwork and communication
CUSP for Safe Surgery (SUSP)
A D A P T I V E C O M P O N E N T S O F S U S P
SUSP Implementation:Learning From Defects 9
Principles of Safe Design
• Patient safety is a property of systems
• Apply principles to both technical tasks and adaptive teamwork
• Teams make wise decisions when input is diverse, independent and encouraged
Standardize Care
Create Independent
Checks
Learn from Defects
SUSP Implementation:Learning From Defects 10
Problem Solving Hierarchy
First-order Problem Solving• Recovers for one patient,
but does not reduce risks for future patients.
• Example: You get the supply from another area or you manage without it.
Second-orderProblem Solving• Reduces risks for future
patients by improving work processes and increasing compliance.
• Example: You create a process to make sure line cart is stocked with necessary equipment.
SUSP Implementation:Learning From Defects 11
Problem Solving Goal: Long-term Solution
11
First-order problem solving
Second-order problem solving
What is the long-term impact on safety culture?
SUSP Implementation:Learning From Defects 12
What Is a Defect?
12
Anything you do not
want to happen again.
SUSP Implementation:Learning From Defects 13
Individual Mistake or System Failing?
13
Rather than being the main instigators of an
accident, operators tend to be the inheritors
of SYSTEM defects. . . . Their part is that of
adding the final garnish to a lethal brew that
has been long in the cooking.
-- James Reason, Human Error, 1990
“
”
SUSP Implementation:Learning From Defects 14
Source of Defects
• Adverse event reporting systems• Sentinel events• Claims data• Infection rates• Complications• Staff Safety Assessments (SSA)
– How will the next patient be harmed?– What can you do to prevent or minimize this harm?
SUSP Implementation:Learning From Defects 15
Polling Question
Have you administered Staff Safety Assessment to frontline staff?
– Yes– No
SUSP Implementation:Learning From Defects 16
What happened?From view of person involved
Why did it happen?
How will you reduce it happening again?
How will you know the risk is reduced?
1234
Learning From Defects
SUSP Implementation:Learning From Defects 17
Who Should Use the LFD Tool?
• Core CUSP team guides the use of this tool– CUSP Facilitator– CUSP Champion– Unit Manager– Provider Champion– Senior Executive
• Everyone on the unit can and should participate in the process of learning from defects
SUSP Implementation:Learning From Defects 18
Checking Your Assumptions
• CUSP brings a diverse group of team members together• Don’t assume that everyone is as familiar with the details of a
defect as might be– Not familiar with the context of a defect being discussed?
Do not hesitate to ask basic questions!– Well-versed? Take the time to describe a defect so
everyone can help you see aspects of a defect you may not have appreciated before
• Walk the process with the frontline staff
SUSP Implementation:Learning From Defects 19
What Happened?
• Reconstruct the timeline and reenact what happened• Dig down to the reasoning and emotions behind actions
and decisions• Consider using visualization tools to break down complex
defects and discover where steps go wrong– Process mapping– Diagrams– Sketches– Role playing
Walk the process
Tip: Take time to listen. Seek to understand rather than to judge. Ask clarifying questions
and follow-up questions.
SUSP Implementation:Learning From Defects 20
What Happen
ed?
Who was involved?
What actions occurred?
What were care team members
thinking and feeling?
What were patients
thinking and feeling?
What was happening at
the same time?
What happened that
had a good outcome?
What tools or technologies were being used and
how?
What Happened?
SUSP Implementation:Learning From Defects 21
Why Did It Happen?
• Develop a “system perspective” to see the hidden factors that led to the event
• List all contributing factors and identify whether they harmed or protected the patient
• Build second-order problem solving skills necessary to learn from defects
Tip: Process mapping will uncover workflow issues, but it won’t get at values, attitudes, and beliefs impacting a defect. Thinking about the “people side” of a defect is critical to understanding how to create lasting change.
Critical to include adaptive teamwork concerns
SUSP Implementation:Learning From Defects 22
System Failure Cascade
Patient suffers
Pronovost Annals IM 2004; Reason
1st
2nd
3rd
5th
4th
Why Did It Happen?
SUSP Implementation:Learning From Defects 23
Hospital
Departmental Factors
Work Environment
Team Factors
Individual Provider
Task Factors
Patient Characteristics
Institutional
Adopted from Vincent
System Factors Impact Safety
SUSP Implementation:Learning From Defects 24
LFD Tool Contributing Factors
SUSP Implementation:Learning From Defects 25
LFD Tool Contributing Factors
SUSP Implementation:Learning From Defects 26
LFD Tool Contributing Factors
SUSP Implementation:Learning From Defects 27
Why Did It Happen?
• As you identify contributing factors, try to go deeper• The “5 Why’s” technique can help
– Why 1: Why did this contributing factor occur?– Why 2: Why did “Why 1” occur?– Why 3: Why did “Why 2” occur?– Why 4: Why did “Why 3” occur?– Why 5: Why did “Why 4” occur?
• It may take more than one meeting or additional fact-finding to find all contributing factors
SUSP Implementation:Learning From Defects 28
Why Did It Happen?
• If your team used a drawing to illustrate what happened, consider going back to it.
• Look for weaknesses in the processes– Are there redundant steps?– Are there variables that make care inconsistent
among providers?• Evaluate the way your workspaces are designed
– Is the workflow reasonable?– Is the workflow efficient?
Make it visual
SUSP Implementation:Learning From Defects 29
• What about the people side of the defect?• Can you identify where the pain points are?• Are there aspects of your patient safety
culture that promote doing the wrong thing or engaging in a risky workaround?
• What might your team do to build a stronger safety culture?
Thinking about culture
Why Did It Happen?
SUSP Implementation:Learning From Defects 30
CASE STUDY: RENAL TRANSPLANTCommunicating for Patient Safety
SUSP Implementation:Learning From Defects 31
• Who: An ICU patient bleeding after renal transplant• What: Needs emergency surgery to correct• When: Early morning 0530• Where: Taken to OR by anesthesiology team• And: Nurse hands over chart with Kardex stamp plate
as patient is on the way out of ICU
What happened next?• In OR: Patient unstable on arrival to OR at 0600,
necessitating additional lines• In OR: Patient stabilized and surgery begins
Setting the stage
Case Study: Renal Transplant
SUSP Implementation:Learning From Defects 32
Case Study: Renal Transplant
• Attending anesthesiologist called to an emergent neurosurgical case for craniotomy
• Attending leaves renal transplant case, returns at 0730• Meanwhile, nursing and OR tech staff turned over at 0700 • Anesthesiology resident who started the case has already signed
out to the day shift resident who has taken over• Attending notes that a transfusion has started, and that the PRBCs
bag has the wrong patient’s name• Attending immediately stops the transfusion, reporting error to the
OR staff and blood bank
SUSP Implementation:Learning From Defects 33
Case Study: Renal Transplant
• Resident used stamp plate to order and then check the blood
• However, wrong chart sent with patient from ICU• Never checked against wrist band• All of OR documents stamped with name from
incorrect chart• Ultimately, patient dies, though transfusion not the
cause as donor blood was type O
SUSP Implementation:Learning From Defects 34
Case Study: Renal Transplant
• What happened?• Why did it happen?
Activity: Where are the system failures?
Learning from Defects Tool
SUSP Implementation:Learning From Defects 35
SYSTEM FAILURES
Case Study: Renal Transplant
Knowledge, Skills & CompetenceAnesthesiology attending not notified of the transfusion; wrist band checks with stamp plate were not done at multiple points
Unit EnvironmentNear simultaneous emergent events; change of two different provider groups at same time; no independent check
Other FactorsHospital environment: Transfer across unitsPatient characteristics: High acuityTask characteristics: Blood check-in only as good as existing identity documents
Create independent checks, encourage patient safety culture initiatives, add system constraints like barcoding technologies
Stagger staff changesFormalize hand-offs between departments
Ensure hand-off process supports emergencies
OPPORTUNITIES FOR IMPROVEMENT
SUSP Implementation:Learning From Defects 36
Action Plan
• Review the Learning from Defects tool with your team
• Collect defects in your operating rooms• Select a defect• Identify the top three contributing factors• Share those factors on the next coaching call
SUSP Implementation:Learning From Defects 37
RESOURCES
Find the Learning from Defects Tool at https://armstrongresearch.hopkinsmedicine.org/susp/cusp/resources.aspx
SUSP Implementation:Learning From Defects 38
References
Bagian JP, Lee C, et al. Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. Jt Comm J Qual Improv 2001;27:522-32.Pronovost PJ, Holzmueller CG, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf 2006;32(2):102-108.Pronovost PJ, Wu Aw, et al. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Int Med 2004;140(12):1025-1033.Reason J. Human Error. Cambridge, England: Cambridge University Press, 2000.Vincent C, Taylor-Adams S, Stanhope N. Framework for analyzing risk and safety in clinical medicine. BMJ. 1998;316:1154.Wu AW, Lipshutz AKM, et al. The effectiveness and efficiency of root cause analysis. JAMA 2008;299:685-87.