2014 Patient Advocacy Issues - How to Tell if Your OR team is an HRO

Is Your Organization a HRO?
(High Reliability Organization)
How can you tell? If not, why Not ?
David Eibling
University of Pittsburgh, VA Pittsburgh
CRNA Conference April 11, 2014
What is a
“High Reliability Organization” ?
Work groups that function in high stress
– Highly Complex
– Tightly Coupled
– High levels of Uncertainty
– High Production Pressure
And – have fewer adverse events than
Seemingly exempt from “Normal Accidents”
“Normal” Accidents
Classic research by Perrow, Sagan and
 Studied accidents that occured during
“normal” operations
– Nuclear power, Petro-chemical plants
Accident rate and impact modified by
numerous factors
“Accidents are Inevitable in complex and
tightly coupled systems”
Sagan 1993
Examples of HROs
Navy carrier operations
 Space Shuttle flights
– Despite two catastrophic crashes
Commercial aviation
There is a science!
Deciphering the “R: in HROs
Research dates back to 1980’s
 Organizational Theory researchers
– LaPorte, Rochlin, Roberts, Weick,
– Why do Organizations do what they do?
Extensive literature
– Academics tend to be in schools of
business and public policy
Science just starting to be recognized in
Characteristics of
High Reliability Organizations
Preoccupation with Failure
– What could happen?
Reluctance to Simplify
– Always more complex than seems
Sensitivity to Operations
– What are we doing?
Commitment to Resilience
– What will stop the chain of error?
Deference to expertise
– Not always apparent who has it
Where is Healthcare?
Medical Error 8th most
common cause of death
in US
– Recent paper suggests is
3rd most common*
Chances of ADE range
from 2 -7 /100
Everyone has a story
Doesn’t seem very reliable
*James Journ Pat Safety 2013
Lets go back 40 Years to
George Foreman knocks out Joe Frazier
Howard Cosell shouts “Down goes Frazier,
Down goes Frazier, Down goes Frazier”
Yon Kippur war
OPEC cuts off oil
Henry Kissinger wins
Nobel Peace Prize
Watergate Hearings begin
Rose Mary Woods accidentally
erases the tape
Pioneer 10 sends back first
close-up pictures of Jupiter
Monica Lewinski is
Emergency Rooms are
just rooms –
Eibling begins his internship at
Wilford Hall, San Antonio Tx
A tale of multiple errors
18 Y/O man falls/jumps from 3rd floor
– Chest trauma
Transported to Wilford Hall USAF Med
 On-call surgeon (Eibling) paged STAT
– mid – July 1973
A tale of multiple errors
Patient combative, pale,
 Unable to obtain vital signs
 Obvious contusion over lateral
 Reduced breath sounds
 Paged Thoracic surgery STAT
 #14 angio placed in hand
A tale of multiple errors
IV lost immediately
 Chief of Cardiac surg arrives
 Multiple attempts to restart IV
– Saphenous cut-down attempted
Patient codes
 Patient dies
 Autopsy demonstrates lung laceration &
hemothorax – no liver/spleen lac
A tale of multiple errors
Morbidity and Mortality Conference one
week later
 Focus on Eibling’s actions/lack thereof
didn’t you restrain patient?
didn’t you place antecubital line?
didn’t you place chest tube?
did you wait so long to intubate?
didn’t you call for help?
We couldn’t imagine that . .
The system could be improved
 Dedicated Emergency Medicine physicians
would improve outcomes
 Trauma teams should take group call
– Rapid response teams should train together
– That Resuscitation training and ATLS would save
That fixing the intern wouldn’t solve the
 That our system was not “highly reliable”
20 Years Later “Error in Medicine”
JAMA 1994
Error in Medicine
Lucian Leape JAMA 1994
Landmark Paper tying Concepts of Human
Error (by Reason) to Medical Error
 Amazingly pertinent even today
 Emphasized extent of problem
– Harvard Medical Practice study 1991
Quoted Schimmel’s 1964 report
– Prospective analysis of 1014 medicine patients at
Yale-New Haven Hospital
Emphasized value of voluntary reporting “at
the bedside by the caregivers themselves”
To Err is Human
Institute of Medicine 1999
Emphasized role of human error in poor
Estimated Medical Error Results in 44,000 98,000 deaths yearly in US
(Actual figures much greater)
Emphasized necessity of studying errors
The title tells it all . . . .
Humans are Imperfect – we must design
systems that take such imperfections
into account
Are we there Yet?
Consensus is no
since 1999 To Err
is Human
Progress has been made –
But has been incremental – not Transformational*
Pre-procedure checklists
Bar coding
Time out
CPRS Alerts
Marking sites
Medication safety
Learning from mistakes
Avoid reliance on memory
Root Cause Analysis
Hand hygiene focus
Using Checklists
Patient Safety Goals
Team huddles
*Anesthesia may be
exception to the rule
“There is nothing New Under the Sun”
“Human Error in medicine,
and the adverse events that
may follow, are problems of
psychology and engineering,
not of medicine”
John Senders, Chapter 9 Human Error in Medicine
Maybe this story will help explain it . . . . . . . .
Who is to Blame?
The Patient – 2013
60 y/o smoker with 2 cm pleomorphic adenoma
On VA disability for PTSD, tinnitus, hearing loss, diabetes
(HbA1c 9.9)
Additional co-morbidities: hypertension, hyperlipidemia, prior
gastric bypass for morbid obesity, prior CABG, known OSA,
known ETOH abuse history
Multiple medications managed by non-VA primary care doctor
(“shared care”)
– Patient not aware of medications/doses “my wife manages my
Preop eval by IMPACT clinic
– Med list in CPRS reviewed
– Some meds from VA, some from outside pharmacy
– Wife not present for IMPACT, no information from non-VA PCP
Who is to Blame?
The Case
Uneventful Parotidectomy
– Post-op hypertension to systolic >200
Urgent medicine consult
HTN - likely multifactorial given anxiety w/o SSRI, pain, ?OSA, CKD and likely under-treated HTN at baseline with goal BP
~130/80. on metoprolol currently as outpatient only which is less than ideal. allergy to Ace/ARB documented and with GFR ~30
HCTZ likely to be less effective. Would recommend starting 2.5 mg of amlodipine now, restarting his SSRI at home
dose, continuing Metoprolol and treating pain PRN. prn hydralazine or clonidine as needed for SBP>180. Would recheck Chem8
in AM.
Small hematoma opened prior to DC
– Discharged on prior medication regimen
– New BP med missed in discharge orders (communication failure?
 In dictated DC summary, not on nursing DC note
ER 2 days later admitted 6 days post op for additional
management with uncontrolled hypertension
– Med consultant discovered prior (non-VA PCP) dosing of
metoprolol as well as missing ACEI/diuretic combo not reflected
in any available med list
Who is to Blame?
“Shared care” – Care coordinated with VA and non-VA
– Exception rather than rule (most frequent example is
– Extensive templated notes 1 yr and 6 months previously –
“Medications reconciled”
– No data from outside PCP in most cases
VA med co-pay $9.00 per month per med (NSC).
Generic meds at Wallmart $4.00 per month or $10.00
for 3 months. ($68 per med per year)
– What would YOU do?
– Relies on human to enter/update non-VA meds
Medication Recognition?
Assigning Blame
Medication reconciliation known problem
– Failure to “reconcile” at discharge well known issue
– No single time-linked display of medications across continuum
of care
Previously reported to internal system- 3 work groups
have addressed
– Pharmacy work group developed single combined list of all
meds (multiple problems such as duplicates)
– Engineering group – formal study instituted by Patient
Safety group concluded that with constraints of
information system best solution is to assign dedicated
pharmacist to inpatient med-rec
Level 3 Peer review level assigned to attending for
all medication reconciliation errors
What do you think has happened?
“It will be evident to anyone who has read the foregoing
pages, that the history of the problem of error does not bear
witness to a steady and well defined progress, from initial
perplexity, through stages of ever increasing light, up to a final
and triumphant solution. Perhaps it was hardly to be expected
in the case of a question so baffling in itself, so open to
evasions, and so dependent on others of positive interest.
The same difficulties keep coming back
under slightly difficult forms, the same postulates
and general distinctions, the same ambiguities and
incoherences; til one begins to wonder whether after all it is
possible to give a rational and philosophic account of this
irrational product of the mind”
Keller The problem of error from Plato to Kant 1934
And just this Monday . . . .
Finding med list from “Spoke” Hospitals
(Don’t appear in CPRS Meds Tab)
Click here
But this only lists meds from VA Pharmacy
Here’s how you find the rest of them
To find all meds from spokes you need to go to “Health Summary”
(near bottom of list)
Click to open Clarksburg Health Summary
Now this list opens in Health Summary
(partial list – too long for slide)
Click on Medication Reconciliation
Now click on the specific site health summary “Med Rec”
Non-VA Meds NOT in Pharm Tab
Dutasteride (twice)
Latanoprost (twice)
Lodrane D herbal??
What would an HRO Do?
Preoccupation with Failure
Reluctance to Simplify
Sensitivity to Operations
Commitment to Resilience
Deference to expertise
Can we use an event as a “biopsy” ?
What would an HRO Do?
Preoccupation with Failure
– Constantly asking “why do we have so many med rec errors?”
– Med rec failures would demand high level attention
– Leadership would feel responsible and insist on a solution
Reluctance to Simplify
– How does the system work, anyway?
– What are the areas of linkage that contribute to failure?
– What are the “little failures” that combine to cause catastrophe?
– What is the context we work in - ie the larger systems such as
medication labeling, cost issues, etc
– Why don’t we understand all of the components and links?
What would an HRO Do?
Sensitivity to Operations
– What is really happening?
– Who at the front line is using work-arounds?
– What are these work-arounds and why are they necessary?
– Who knows what is really happening and is ready to talk about it?
Commitment to Resilience
– Where is the resilience in our system?
– Where is resilience missing?
– Are there areas of tight linkage that impair resilience?
– How can we help our front line people stop the chain of error?
Humans are Source of System
Resiliency and Adaptability
How many times each
day do:
– You
– Your fellow practitioners
– Your colleagues in other
– Your OR nurses
Use a “Work-around” to
solve some problem?
Studying Work-arounds is
recognized as key to
Fix the system, not the human understanding humansystem incompatabilities
What would an HRO Do?
Deference to expertise (Internal)
– Who knows what is going on?
Is it the nurse? Resident? Pharmacist? Patient?
– Who might have ideas on how to reduce the likelihood
of failure?
– Will we heed their observations and recommendations?
– Are they willing to speak up?
“The greatest obstacle to discovery was
not ignorance – it was the illusion of
Daniel Boorstin
How to Find out what “Sharp
End” Practitioners Know ?
“Knowledge is more
than information”
Challenge is to capture
Theme of the “Just
Culture” movement
Overall, healthcare has
done poorly
– 2012 Safety Attitudes
survey - 40% not talking
Involves more than
merely “Reporting”
What would an HRO Do?
– Deference to expertise (External)
– Are we the first to encounter this failure?
– Has this been studied before and where are the reports?
– What are others doing?
– Are we willing to invest the time and resources to attend
meetings and study the literature when it exists?
“Education is learning that you didn’t even know what
you didn’t know”
Daniel Boorstin
Science of Error
Not a new topic
– Cognitive psychologists
Human Error
– James Reason
Cambridge Press 1990
– Precipitated by major
accidents of the 70’s
Attempted to answer the
– Why do we do what we
Leape tied Medical error to
Reason’s work
The famous Swiss-cheese illustration
Deflected Error
Adapted from Reason 1990
An HRO knows
where the
holes are –
and worries
about the ones
it doesn’t
know about
Slip versus Mistake
After Reason
Slip is an error due to failure of
– 1 Qt oil in Radiator
– Occurs at the “Sharp End” of a
Mistake is a fundamental error in
– Often occurs at the “Blunt End” of a
Slips are often due to
mistakes in system design
Human Error
“Natural consequence” of human adaptation
to environmental stimulation
Focusing attention
 Recognizing patterns
 “Filling in the blanks”
 Sequencing events
The same strategies we use to manage
information overload !
Knowledge and error flow
from the same mental
sources, only success can
tell the one from the
Ernst Mach 1905
Human Error – the Scapegoat
Human Error serves
valuable role for
Blaming the human
“absolves” organization
from blame
– Reduces work required
to understand event
– Eliminates need to either
seek or alter underlying
Concept integrated into
culture of medicine
“Any RCA that concludes
“Human Error” was the cause
has fundamentally failed”
(Richard Cook Christopher Nemeth)
“If we design our way
into difficulty we can
design our way out.”
(John Thakara)
AE’s nearly always more complex
than appear initially
Organizations often
restricted by regulatory
forces, competing
national goals, etc.
“Fish can’t see water”
VA examples legendary
– Software issues
Medication recognition
– Patient photo in record
Out of bed
Pain needs
In X-ray
Family visiting
Disease process
An example of complexity
Medication ordering
Correct armband?
Arm Band
How to print?
Competing tasks
Error checking
Information System
Log in tasks
Compatibility with EHR
System reliability
Competing tasks
Physical Environment
Ward lay-out
Equipment fit in room?
Competing tasks take nurse away
A Constant Theme
“The judgment that this was human error
simply produces too many Institutional
“By attributing my colleague’s accident to his inattention or
stupidity, though, I make it possible to believe that the accident
has no relevance for me”
A Tale of Two Stories*
The Front line story versus the
– Focus on individual actions
– Focus on retraining
– Backward vs Forward looking
 “Hindsight Biasis”
First and Second order Problem
*Cook, Woods 1997
**Tucker and Edmundson
First Order Problem Solving
Worker compensates for system
– Classic “work-arounds”
– The “Spackle Resident”
– The system never is changed
Failure recognized as human failure
– Unreliable, inattentive, etc.
Solution is by changing Human or role
in process
Second Order Problem
Assume human actions result of
something (or many things)
Begin by assuming assessments and
actions of humans are predictable
– Seek to understand roles of context and
competing goals as decision architects
– Role of cognitive psychology
Much more challenging
– Incongruent with prominent themes of
Hindsight Bias
¾ of all AEs “Human Error”
Attribution easy when outcome
Causal attribution relies on
social/psychological constructs
– Previous learning
– Context
– Decision architects
Difficulties in “tracing back”
May be impossible to understand
decision-making processes that led to AE
David Woods
4 Reasons to Blame Individual
People are available to
People were there (maybe
even lots of people)
Human performance in
complex systems usually
very good – (humans
compensating for system) hence
AEs are rare
Knowledge of outcomes
when tracing backwards
leads to incorrect
assumptions regarding
cognitive processes
(outcome drives diagnosis)
Finding Out What Happened
Who does it right?
The Aviation
Incentive for US Aviation
Safety Reporting System
Why the emphasis on preventing aircraft accidents?
Public Visibility of aircraft accidents
 Costs
– Economic costs of single event
– Lives lost per event
The pilot is first at the scene!
 Our congressmen fly too
The Aviation Safety Reporting System
How does it work?
No-fault reporting of errors
– No repercussions for pilot if reported in 10 days
De-identified after verification of facts
 Reviewed by panel of retired pilots
 Specific recommendations for system changes
– Changes mandated by regulation
– Disseminated to entire industry
Follow-up to verify compliance
 Establishes a culture of safety
Aviation Safety Reporting System
Note – NASA – Not FAA
How does it work?
The Aviation Industry:
Accepts that Errors Happen
 Works to understand:
– Why? When? Where? “Even the little ones!”
 Begins by Reporting
– No Fault – “Everyone has expertise”
 Looks for root cause(s)
– Defective system – not defective people
Fixes the system – not the individual
 Follow-ups to confirm fix has been implemented
History of Human Factors
Early years of aviation
checkered history
 Aircraft reliability
improved during
 Post-war introduction
of jets did not go well
 Began to realize cause
not the airframe – but
the pilot
Human Error
“If we design our way
into difficulty we can
design our way out.”
(John Thakara)
Human Factors Engineering
A “new” applied science
Military began to realize
aircraft too difficult to fly
 G-forces, dehydration
 New technology
Pressure suits, etc.
 Cockpit controls
 Too much to remember
– Wheels-up landing
– Autopilot programing
AA 965 Dec 21, 1995 Cali
Eastern Flight 401
Human Factors Research in Medicine
Estock et al 2014
Some actions ARE blameworthy
Just Culture in the Aviation Industry
“a no-blame culture is neither feasible nor desirable”
Reason 1997
There are some rules you would
never break
How do we define the line
acceptable and
unacceptable behavior ?
Global Aviation Information Network
Available from
“Just Culture”
There is a “line in the sand” between driving 75 in
a 65 MPH zone versus 75 down Fifth Ave
“A just culture recognizes that competent professionals
make mistakes and acknowledges that even competent
professionals will develop unhealthy norms (shortcuts,
routine rule violations), but has zero tolerance for reckless
(AHRQ website)
“Who draws the line is the
most critical question”
Dekker 2012
Culture of Safety
What is it we are talking about?
Patient Safety is first
– Controversial
Leadership leads safety
 Employees believe safety
top priority for leadership
 Employees empowered to
speak up
 Employees expect
changes will be made to
correct threats to safety
Measured by “Patient
Safety Attitudes Survey”
 Distributed and collated by
 Data published in February
Overall poor results
Most healthcare workers in
US work in systems that
address mistakes with
Leadership is Key
“The most important question in
establishing a Just Culture is Who
gets to decide what is acceptable”
So, What is Our Responsibility?
Recognize that most adverse events are
due to latent errors
 Highlight these latent errors in our
hospitals, clinics, and offices
 Educate leadership to the fundamentals
of a culture of safety
 Accept Responsibility for the Systems of
care in which we care for our patients.
We can help our organizations
become HROs
Begin by Reporting
Recognize that as front end staff YOU
have expertise
 Speak up and encourage others to
 Participate in analyses of failures
– Look for the “second Story”
Don’t accept the Status Quo
High Reliability Organizations
consistently demonstrate a:
Preoccupation with Failure
– What could happen?
Reluctance to Simplify
– Always more complex than seems
Sensitivity to Operations
– What are we doing?
Commitment to Resilience
– What will stop the chain of error?
Deference to expertise
– Not always apparent who has it
We Can
Show the Way

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