I MAKE ERRORS

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I MAKE ERRORS.YOU WILL TOO!
IM A FAILURE.YOU CAN BE TOO!

• Prepared by
• Gord Vail, M.Sc., MD
• Chief of Staff, Hotel-Dieu Grace Hospital
• Windsor ON

2
DISCLOSURES

• Advisory Boards
• ? Hoffman-LaRoche
• ? Bayer
• Sponsored Speaker
• ? Hoffman-LaRoche
• ? Bayer
• ? Sanofi-Aventis
• Educational Grants for HDGH Grand Rounds
• ? Leo Pharma
• ? Sanofi-Aventis

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ERRORS AT WORK

• Categories of errors
• Examples
• Change management
• Why its difficult
• Errors in Administrative Projects

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QUOTE

• A failure is a man who has blundered but is not
• able to cash in on the experience.
• Elbert Hubbard (1856-1915) American author
  philosopher

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GOD SAVE THE THE QUEEN

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QUESTION

• What did the last slide say?

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ATTRIBUTION ERROR

• ? Or pattern recognition error
• ? Why did you see something different?
• ? What conditions occur at work that could make
  such an error occur?
• ? Labeling
• ? Location
• ? Same patient, day after day
• - Chest pain in the ED
• ? Old charts
• ? Our PA example

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THE TYPICAL INNER-CITY ED PATIENT

• Chronic pain/alcoholic/homeless patient in the
  hallway
• Our PA sees them (unusual)
• Finds abnormalities
• If one of the attendings with their past
  experience saw them???

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AN EXAMPLE CLOSE TO HOME

• General surgeon gets a referral
• ?Breast cancer
• U/S ordered by FMD for ?Breast cancer
• U/S report RFR included with referral ?Breast
  cancer
• U/S guided biopsy for ?Breast cancer
• Pathology report RFR ?Breast cancer
• What do you think happened?
• Actual diagnosis on pathology NOT breast cancer

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CONFIRMATION BIAS

• We try to find data that will support our
  hypothesis
• What gets written on a chart is your
  interpretation of the interaction
• What do you ignore in your practice?
• Typical chest pain
• Usual IVDA patient
• Psychiatry patients with medical illnesses
• How can you avoid this?
• Truly listento the patient and that voice in
  your head!

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IMPLEMENTING CHANGE

• My story
• HDGH LEAN Initiatives
• Dr. David Ng I
• Leadership
• Computerization of the ED
• What did it show?
• What learnings came out?

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WHICH PROJECT SUCCEEDED?

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WHY IS CHANGE IMPORTANT?

• The major problem with planning is that plans
  are virtually always wrong. Brown Eisenhardt
  1998
• The Emergency department is a fairly stable
  environment
• 1 ICU admit/d, 4 medical, 4 hospitalist, 12
  admission rate
• Its the long-term issues facing a hospital that
  change
• Funding
• Technology
• Care models

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IM A FAILURE YOURE GOING TO FAIL

• Management projects failure rate 80
• We have to learn from failure
• Culture of Blame
• If not supportive, whos going to lead a project
  doomed to fail?
• Why try to lead?
• How can you change it?
• Do you really think everyone at your hospital
  wants you PIP or P4R to succeed?
• These are the important questions that need to be
  asked!

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RESEARCH COMPONENT

• Everyones involved in before/after scenarios
• Not the most rigorous but still useful
• Will help others
• Our experience with communication
• My colleague/friend in telestroke medicine
• Always need proof (and more proof!) that
  something works
• Ideas for improvement
• Not everything intuitively correct is proven to
  be so

18

• Target patterns of ten shots fired by two
  riflemen. As pattern exhibits no
• constant error, but rather large variable errors.
  Bs pattern shows a large
• constant error, but small errors. (from Chapanis,
  1951).

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THREE TYPES OF HUMAN ERRORS

• 1. Skill Based
• Slips or lapses, i.e. forgetting your keys in the
  a.m.!
• 2. Rule Based
• Brain processes
• Go back into your experience and find correct
  response, for example a differential diagnosis
  for SOB
• 3. Knowledge Based
• Lack of knowledge
• Shouldnt reach the patient
• Barriers such as co-signing for clerks/residents
• James Reasons Swiss Cheese model from 1990
• Puts up barriers to prevent the error from
  propagating
• STAR technique used to assist with prevention
• Stop, think, act, review

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THE SWISS CHEESE MODEL

• The Swiss cheese model of how defenses, barriers,
  and safeguards may be penetrated by an accident
  trajectory.

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HIERARCHAL ERRORS

• Usual example to start with is pilots
• Who flies?
• See any relation to medicine?
• Who tells on an attending when youre in
  training?
• Cultural change
• Errors are talked about
• Legislated in Canada about when how to disclose
  an error
• Can work for you
• Examples from the leaders filter down
• An example from HDGH is Hand washing!

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PERSON OR SYSTEM APPROACH?

• Person focuses on the individual
• Forgetfulness, inattention or moral weakness
• System looks at conditions around persons work
• Build defenses to avert or mitigate an errors
  effects
• But, isnt blaming an individual easier more
  satisfying??
• Less institutional responsibility
• Less time consuming
• No work to fix just eliminate the individual

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SUMMARY

• Leaders in the crowd
• Be kind!
• Acknowledge your failures and errors Powerful to
  those you work with.
• Think of the big picture
• One person made the error thats going to allow
  you to rework the system that led to the error
  Difficult to do but necessary
• Keep trying things
• Hit that 20 goal!

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THANK YOU!

• QUESTIONS OR COMMENTS?