Creating a New Foundation of Safety

1
Creating a New Foundation of Safety
2
Highlights

• Institute of Medicine Report What did it mean?
• Human error as risk factor for adverse events in
  health care
• A scientific approach to the understanding and
  management of human error
• Implications for improving safety and developing
  an effective safety culture

3
To Err is Human Building a Safer Health System
IOM, 1999

• Results of studies in New York, Colorado, and
  Utah imply that from 44,000 to 98,000 Americans
  die each year as a result of medical errors
• Total national costs (lost income, disability,
  health care costs) from 17 to 29 billion from
  preventable adverse events

4
Interpretation depends on point of view (1)

• Public learns of the impact of medical error and
  sees a health care system populated by the
• Uncaring
• Incompetent, careless
• Uncommitted
• Greedy
• This interpretation is a result of the
  fundamental attribution error

5
Interpretation depends on point of view (2)

• Health care providers know their own motives and
  the character of their colleagues
• Caring, careful
• Skilled, educated, competent
• Devoted, committed
• The IOM data must be wrong good people cant
  produce such bad outcomes
• This interpretation is a result of the
  fundamental surprise error

6
Learning from Error and Accidents

• I-15, Salt Lake City, Utah (see Salt Lake Tribune
  article)
• 1.5 billion upgrade to the interstate system
• 4 years of construction
• Official opening in the spring of 2001
• People went the wrong way on the 4th South
  high-occupancy vehicle off-ramp

7
I-15, Salt Lake City
400 S.
I-15 South
I-15 North
HOV Entrance
HOV Exit
North
8
Understanding errorthe I-15 situation

• A closer look at the article drivers were going
  up the off-ramp in spite of
• Arrows showing the right direction
• Signs flashing Wrong Way
• (Eventually) Concrete barriers (!)
• Naturally, motorists entering the wrong way on a
  freeway would be in for a dangerous surprise.

9
Understanding errorthe initial response

• What do we do with drivers who exhibit such
  reckless behavior?
• 30 citations in a few minutes
• Later switched to warnings 145 warnings in
  less than 2 hours
• (Subsequently changed citations to warnings)
• Closed the off-ramp altogether

10
Understanding errordigging shallow

• people arent paying attention

11
Understanding errordigging deeper

• Some other features
• These ramps enter and exit the freeways on the
  left a design unique in Utah
• For over a year, and until recently, this very
  off-ramp had been used as an on-ramp
• Eventually, the intersection was re-designed with
  a longer median, striping, and additional signage.

12
Extended Median
400 S.
I-15 South
I-15 North
HOV Entrance
HOV Exit
North
13
Understanding errorhealth care contrasts and
parallels

• Why this example?
• Punitive response to error
• This system corrected itself why?
• Learning from error

14
Punishing error

• I-15
• Citations and warnings
• Why didnt this work?
• Health care
• Loss of license, suspension, disciplinary
  actions,
• Why doesnt this work?
• What side-effects does it have?

15
Correcting the system

• I-15
• Ended punitive response, physical re-design
• Why didnt they continue to give out tickets or
  increase fines?
• Health care
• System correction is possible by similar
  strategies
• What challenges can we expect?

16
Learning from error

• How to proceed?
• Recognize that we are all subject to the
  fundamental attribution error
• Recognize that we may be subject to a fundamental
  surprise error
• Recognize the dangerous off-ramps designed into
  the system
• See errors as indications of system problems
• Move beyond common sense design

17
Learning from error and developing an effective
safety culture

• A safety culture produces and is a product of
• The meaning assigned to errors and accidents
• An indication of problems with staff motivation,
  competence, caring, commitment?
• Windows into the workings of the system,
  opportunities for fundamental surprise,
  opportunities for learning
• The methods used to manage error
• Common sense task design and information
  management strategies
• Scientific disciplines successfully applied in
  other high-hazard settings

18
(No Transcript)