Is Your Organization a HRO? (High Reliability Organization) How can you tell? If not, why Not ? David Eibling Universit

1. 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

2. What is a “High Reliability Organization” ? Seemingly exempt from “Normal Accidents” • Work groups that function in high stress environments • Highly Complex • Tightly Coupled • High levels of Uncertainty • High Production Pressure • And – have fewer adverse events than expected

3. “Normal” Accidents “Accidents are Inevitable in complex and tightly coupled systems” Sagan 1993 • Classic research by Perrow, Sagan and others • Studied accidents that occured during “normal” operations • Nuclear power, Petro-chemical plants • Accident rate and impact modified by numerous factors

4. From NASA PPT

5. Examples of HROs There is a science! • Navy carrier operations • Space Shuttle flights • Despite two catastrophic crashes • Commercial aviation

6. Deciphering the “R: in HROs • Research dates back to 1980’s • Organizational Theory researchers • LaPorte, Rochlin, Roberts, Weick, Schulman • 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 medicine

7. Characteristics ofHigh 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

8. Where is Healthcare? Doesn’t seem very reliable • 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 *James Journ Pat Safety 2013

9. Lets go back 40 Years to 1973 Yon Kippur war OPEC cuts off oil George Foreman knocks out Joe Frazier Howard Cosell shouts “Down goes Frazier, Down goes Frazier, Down goes Frazier”

10. 1973 Henry Kissinger wins Nobel Peace Prize Watergate Hearings begin Rose Mary Woods accidentally erases the tape

11. 1973 Pioneer 10 sends back first close-up pictures of Jupiter Monica Lewinski is born

12. 1973 Emergency Rooms are just rooms – Eibling begins his internship at Wilford Hall, San Antonio Tx

13. A tale of multiple errors • 18 Y/O man falls/jumps from 3rd floor barracks • Chest trauma • Transported to Wilford Hall USAF Med Center • On-call surgeon (Eibling) paged STAT • mid – July 1973

14. A tale of multiple errors • Patient combative, pale, tachypneic • Unable to obtain vital signs • Obvious contusion over lateral thorax • Reduced breath sounds • Paged Thoracic surgery STAT • #14 angio placed in hand

15. 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

16. A tale of multiple errors • Morbidity and Mortality Conference one week later • Focus on Eibling’s actions/lack thereof • Why didn’t you restrain patient? • Why didn’t you place antecubital line? • Why didn’t you place chest tube? • Why did you wait so long to intubate? • Why didn’t you call for help?

17. 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 lives • That fixing the intern wouldn’t solve the problem • That our system was not “highly reliable”

18. 20 Years Later “Error in Medicine” JAMA 1994

19. Error in MedicineLucian 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”

20. To Err is HumanInstitute of Medicine 1999 Emphasized role of human error in poor outcomes 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

21. Are we there Yet? Consensus is no substantial improvement since 1999 To Err is Human

22. Progress has been made – But has been incremental – not Transformational* • Pre-procedure checklists • Time out • Marking sites • Medication safety • Learning from mistakes • Root Cause Analysis • Using Checklists • Patient Safety Goals • Team huddles • Hand off communication tool • Bar coding • CPRS Alerts • Simplification • Standardization • Avoid reliance on memory • Hand hygiene focus *Anesthesia may be exception to the rule

23. “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

24. WHY so little Improvement ? Maybe this story will help explain it . . . . . . . .

25. 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 medications” • Preopeval 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

26. 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 metoprololcurrently 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 Metoprololand 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? slip?) • 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

27. Who is to Blame?Context • “Shared care” – Care coordinated with VA and non-VA PCP • Exception rather than rule (most frequent example is anticoagulation) • 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?

28. Assigning Blame What do you think has happened? • 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

29. Keller The problem of error from Plato to Kant 1934 “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”

30. 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

31. To find all meds from spokes you need to go to “Health Summary” (near bottom of list) Clarksburg Erie Pittsburgh Click to open Clarksburg Health Summary

32. Now this list opens in Health Summary (partial list – too long for slide) Click on Medication Reconciliation

33. Now click on the specific site health summary “Med Rec” Non-VA Meds NOT in Pharm Tab Asprin Atorvastatin Budesonide Celecoxib Dutasteride (twice) Lansoprazole Latanoprost (twice) Levothyroxine Metformin Metasone Lodrane D herbal?? Patanase Olopatadine Pioglitazone Ramipril Terazosin

34. What would an HRO Do? Can we use an event as a “biopsy” ? Preoccupation with Failure Reluctance to Simplify Sensitivity to Operations Commitment to Resilience Deference to expertise

35. 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?

36. 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?

37. Humans are Source of System Resiliency and Adaptability • How many times each day do: • You • Your fellow practitioners • Your colleagues in other specialties • Your OR nurses • Use a “Work-around” to solve some problem? Studying Work-arounds is recognized as key to understanding human-system incompatabilities Fix the system, not the human

38. What would an HRO Do? “The greatest obstacle to discovery was not ignorance – it was the illusion of knowledge” Daniel Boorstin • 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?

39. How to Find out what “Sharp End” Practitioners Know ? • “Knowledge is more than information” • Challenge is to capture knowledge • Theme of the “Just Culture” movement • Overall, healthcare has done poorly • 2012 Safety Attitudes survey - 40% not talking • Involves more than merely “Reporting”

40. What would an HRO Do? “Education is learning that you didn’t even know what you didn’t know” Daniel Boorstin • 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?

41. 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 question • Why do we do what we do? • Leape tied Medical error to Reason’s work

42. The famous Swiss-cheese illustration Deflected Error Triggers An HRO knows where the holes are – and worries about the ones it doesn’t know about Accident Defenses Adapted from Reason 1990

43. Slip versus MistakeAfter Reason • Slipis an error due to failure of execution • 1 Qt oil in Radiator • Occurs at the “Sharp End” of a system • Mistake is a fundamental error in judgment • Often occurs at the “Blunt End” of a system • Slips are often due to mistakes in system design

44. 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 !

45. Knowledge and error flow from the same mental sources, only success can tell the one from the other.” Ernst Mach 1905

46. Human Error – the Scapegoat • Human Error serves valuable role for organizations • Blaming the human “absolves” organization from blame • Reduces work required to understand event • Eliminates need to either seek or alter underlying source(s) • 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)

47. 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

48. BCMA – An example of complexity Out of bed Pain needs In X-ray Disease process Patient Family visiting location Medication ordering workflow Pharmacy labeling Correct armband? How to print? Arm Band Competing tasks location Error checking Usability Information System Log in tasks Compatibility with EHR System reliability Nurse workload Doctor Interruptions Competing tasks Physical Environment Ward lay-out Competing tasks take nurse away Equipment fit in room?

49. A Constant Theme “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” “The judgment that this was human error simply produces too many Institutional Benefits” Dekker

50. A Tale of Two Stories* *Cook, Woods 1997 **Tucker and Edmundson • The Front line story versus the investigation • Focus on individual actions • Focus on retraining • Backward vsForward looking • “Hindsight Biasis” • First and Second order Problem Solving**