Transcript HRO

The High Reliability
Emergency Department
Grand Rounds December 7, 2011, SJRMC
David J. Adinaro MD, MAEd, FACEP
Chief, Adult Emergency Department, EM Residency Research Director
Disclosures
I have nothing to report in
terms of financial
disclosures.
Biases
I believe
 That I have the best job in the
world
 That I work with the best
people in the best profession
 That we do noble work
 That we can do better
Objectives
» Understand the concept of
HROs
» Identify the similarities
between EDs and other
HROs
» Identify ways to be more
mindful in our everyday
care of patients
Definitions
» High Reliability Organizations
HRO
A High Reliability Organization (HRO) is an organization
that has succeeded in avoiding catastrophes in an
environment where normal accidents can be expected
due to risk factors and complexity
Definitions
» A NORMAL ACCIDENT or SYSTEM ACCIDENT is an
“unanticipated interaction of multiple failures in
a complex system”.
» Requires both INTERACTIVE COMPLEXITY and
TIGHT COUPLING to be present in the system.
Reason’s Model of Normal Accidents
Example of Normal Accident
» Trauma patient suddenly becomes unresponsive
and apneic shortly after extubation s\p
diagnostic work up in the Emergency
Department of a Level I trauma center.
» Requires emergent reintubation for a short
period of time.
Example of Normal Accident
» Hospital policy of properly labeling unmarked
meds not routinely followed.
» Standardized labeling not available.
» Teams performing intubations do not routinely
ensure\witness proper disposal of dangerous
medications.
Example of Normal Accident
» In order to flush Hep Lock nurse uses apparently
unused normal saline in 10cc syringe left at
bedside
» Prepackaged flushes not routinely available so NS
generally drawn into similar 10cc syringes.
Example of Normal Accident
» RESULTS: Patient is unintentionally injected with
60-80mg of Succinylcholine.
Example of Normal Accident
» Take a moment to write down an example of a
NORMAL ACCIDENT you witnessed, participated
in, and\or prevented recently.
Reason’s Model of Normal Accidents
Environment of an HRO
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Hypercomplexity - HROs exist in complex environments that depend on multiteam systems that must coordinate for safety
Tight coupling - HROs consist of tightly coupled teams in which the members
depend on tasks performed across their team
Extreme hierarchical differentiation - In HROs, roles are clearly differentiated
and defined. Intensive coordination efforts are needed to keep members of
the teams working cohesively
Multiple decision makers in a complex communication network - HROs
consist of many decision makers working to make important, interconnected
decisions
High degree of accountability - HROs have a high degree of accountability
when an error occurs that has severe consequences
Need for frequent, immediate feedback - HROs exist in industries where
team members must receive frequent feedback at all times
Compressed time constraints - Time constraints are common to many
industries, including health care
HRO Principles
» 1) Preoccupation with failure » 4) Commitment to
resilience
» 2) Reluctance to simplify
» 5) Deference to
» 3) Sensitivity to operations
expertise
HRO
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Aircraft carrier flight operations
Nuclear Power Plants
Fireground Operations (especially wildfire)
Emergency Departments!
HRO Principle #1
Preoccupation with failure
• Encourage reporting of errors
• Treating any lapse as a symptom that something may be
wrong with the system.
• Using near-misses for what can be learned.
• Accepting that small failures can have an additive effect and
lead to Natural Accidents.
• Continually articulating mistakes they don’t want to make.
HRO Principle #1
Preoccupation with failure
• Naval Flight Operations
• Obsessed with finding failure.
• Every landing is televised, reviewed, graded, and grades
used to improve performance.
• Everyone sees how everyone else performs.
• Near Misses
• Debriefed within the hour.
• Everyone documents what they saw and\or heard prior to
incident.
• Treated as signs of potential larger problems.
Crashes spur Navy to ground all its aircraft for safety review
ACROSS THE NATION
March 05, 2006|By Items compiled from Tribune news services.
WASHINGTON, D.C. — Plagued by a series of helicopter and jet crashes in recent months, the
Navy has decided to ground all its aircraft for half a day this week for an internal safety review.
The stand-down will affect 3,800 aircraft and thousands of naval aviation personnel, including
aircraft on 12 carriers around the world. It is the first time since 1997 that such a pause in flight
operations across the Navy has been ordered.
Since Oct 1. there have been major crashes that resulted in loss of life or of the aircaft. Nine
aircraft were destroyed and 10 aviators killed.
HRO Principle #1
Preoccupation with failure
• Examples of Violations
– Bent Spear – USAF Nuclear Weapons Incident
» Warheads left without special protections for 36 hours
after mistakenly being loaded on B52
» Investigations show multiple near misses prior.
» Resignations starting with Secretary of Air Force.
» Changes to handling procedures\training.
HRO Principle #1
Preoccupation with failure
• Examples of Violations
– Cerro Grande Fire
» Planned “Prescribed Fire” of 300 acres near Santa Fe, NM.
to reduce risk of wildfires.
» Crew of 20 Firefighters ignite a 3 foot perimeter before
planning to burn interior.
» Failures noted to contain perimeter fires prior to burn of
interior.
» 15 days later fire finally under control after being fought by
1,000 firefighters burning 48,000 acres and causing $1
billion in damage.
HRO Principle #1
Preoccupation with failure
• Emergency Department
– Incident Reporting
– EDQA Process
» 400 charts and still going
» Large focus on systems issues
– Need to change disincentives for reporting errors.
– Need to recognize near-misses as small failures.
HRO Principle #2
Reluctance to Simplify
• Less Simplification = Broader awareness.
• A view that the world is complex, unstable, unknowable, and
unpredictable.
• Welcomes diverse experience, skepticism toward received
wisdom.
• Understands that superficial similarities between the present
and the past mask deeper differences that could prove fatal.
• Mindfulness – to have a rich awareness of discriminatory
detail and enhance ability to discover and correct errors that
could escalate into a crisis.
HRO Principle #2
Reluctance to Simplify
• NASA (Columbia Space Shuttle Accident)
• Tendency to simply problems.
• Distinction between “in-family” and “out-of-family”
problems.
• “In-family” label used for problems already analyzed and
understood.
• Burn marks to O-Rings noted on earlier flights.
• After analysis this was determined to be an “in-family”
problem.
HRO Principle #2
Reluctance to Simplify
• NASA (Columbia Space Shuttle Accident)
• Continued concerns about O-Rings ignored as they were
already determined “in-family”.
• Multiple waivers granted related to O-rings.
• January 28, 1986 Challenger broke apart 73 seconds into
launch.
• All seven astronauts including civilian teacher killed.
HRO Principle #2
Reluctance to Simplify
• Emergency Department
• Commitment to mindfulness.
• Is that patient supposed to look that way????
• Overcoming reluctance to express concerns.
• Responding immediately to others’ concerns.
• Actively searching for disconfirming data.
HRO Principle #2
Reluctance to Simplify
• Emergency Department
• Simplification a major source of diagnostic medical error.
• Frequently physicians cut off exploration of patient’s
condition too early.
• Use of pattern recognition a double-edged sword.
• Often results in “closest fit” approach.
• Results in missed diagnoses and delayed care.
• Classic example is overdiagnosis of gastroenteritis in other
serious conditions (appendicitis, etc.)
• Healthy skepticism and accounting for all findings help
prevent these errors.
HRO Principle #3
Sensitivity to Operations
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Attentive to the front line.
= Sensitivity to Relationships.
Ensures resources needed to accomplish mission are available.
Works hard to break down silos.
Encourages communication within and between departments.
Attempts to keep focus on the “Big Picture” .
Processes a “near miss” not as success (I caught the patient
before she strangled herself) but as a small failure ((failure to
identify and respond to suicide risk).
• Looks for “small wins” in improving system.
HRO Principle #3
Sensitivity to Operations
• Wildland Firefighting
• Standard analysis of all fires to find errors and ways to
improve.
• Adherence to 10 Standard Fire Orders
1) Keep informed of conditions.
2) Know what your fire is doing at all times.
4) Identify escape routes and safety zones.
6) Be alert. Keep calm. Think clearly. Act decisively.
8) Give clear instructions and insure understanding.
10) Fight fire aggressively, having provided safety first.
HRO Principle #3
Sensitivity to Operations
• Storm King Tragedy (South Canyon Fire 1994)
• 14 highly experienced firefighters lose their lives when the
fire jumps the line they were digging trapping them on a
ridge.
• Overly aggressive tactics combined with lack of support and
no planned escape route.
• Warning of high winds not communicated.
• Later determined leadership at fire scene also lacking.
ED Operations
HRO Principle #3
Sensitivity to Operations
• Emergency Department
• Communication, communication, communication.
• Communicate up, down and around.
• Never assume other possess what you know.
• Report near-misses. Treat them seriously.
• Look for the “small wins”.
HRO Principle #3
Sensitivity to Operations
• Emergency Department – small wins
• Small Wins – produce change without confronting the
system directly or aggressively.
• Recent examples:
• Use of Admin sign to denote pending bed
assignment.
• Pneumonia ABX guide.
• Physician Reference guide.
» Impact is from examples they provide others.
• Through doing something tangible.
• Through showing change is possible.
HRO Principle #3
Sensitivity to Operations
• Emergency Department – small wins
•Write down an issue ripe for a
small win.
HRO Principle #4
Commitment to Resilience
• Intrinsic ability of a system to maintain or regain a dynamically
stable state, allowing continued operations after a major
mishap or in presence of continuous stress.
• Involves recognition that no system is perfect.
• Combination of keeping errors small and of improvising
workarounds to keep system functioning.
HRO Principle #4
Commitment to Resilience
• Emergency Department.
• We own this hands down.
• We operate in a near continual state of stress
that requires significant resilience.
• Our motto: Anyone, Anything, Anytime.
• ‘Nuff said.
HRO Principle #5
Deference to Expertise
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Pushes decision making down and around.
Decisions are made on the front line.
Authority migrates to the people with the most expertise.
Makes an effort to see what people with greasy hands know.
Does not mistake expertise with experts.
HRO Principle #5
Deference to Expertise
• Emergency Department
• At times goes against the hierarchal nature of medicine.
• Does fit in well with the golden rule (when in
doubt….consult).
• Dependent on the free flow of information and respect for
colleagues.
• Made easier when focus is on “Big Picture”.
• Not a sign of weakness.
SJRMC ED Operations
» Embraces many aspects of HRO.
» Expectation of continued
improvement and need for
change is most important asset.
» Improving communication is
crucially important.
» Feedback from the sharp end is
vital.
» [email protected]
» Office: 973-754-3735.
Thank You!