tag:blogger.com,1999:blog-35083058360236320362024-03-16T01:09:39.721+00:00Simulation, Human Factors and Quality of CareThoughts, musings and information from the staff at the Scottish Centre for Simulation and Clinical Human Factors, Larbert.Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.comBlogger82125tag:blogger.com,1999:blog-3508305836023632036.post-7148183807746164732022-03-21T22:10:00.000+00:002022-03-21T22:10:24.428+00:00We need to talk about SBAR<p> You can’t have a discussion about communication without stumbling over the mnemonic SBAR. Transplanted from the US Navy, it is the most common handover tool mentioned in the secondary care debriefs I’m involved with. <table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7yUmRTbePZ54yHt1hjoGaakVjUWzXsr2a-y8z8eTZE5G-FgOlnhlpmrPp7DnaIxj5ykWRLC0v8gtorfXm2zKtXgBlhZK9G_AERNuHohNqZnmGz29EbQIOyodK9aXNWpZGKz-Gqq2O4yiMYihBsO3yOQVy-UaD19qTjH52bDSsNIXMLMWcgI7lk5Ut/s1944/44B04236-E6F8-4F5A-90C0-611B0C14CB8F.jpeg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1944" data-original-width="1435" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7yUmRTbePZ54yHt1hjoGaakVjUWzXsr2a-y8z8eTZE5G-FgOlnhlpmrPp7DnaIxj5ykWRLC0v8gtorfXm2zKtXgBlhZK9G_AERNuHohNqZnmGz29EbQIOyodK9aXNWpZGKz-Gqq2O4yiMYihBsO3yOQVy-UaD19qTjH52bDSsNIXMLMWcgI7lk5Ut/w472-h640/44B04236-E6F8-4F5A-90C0-611B0C14CB8F.jpeg" width="472" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">From <a href="https://www.england.nhs.uk/wp-content/uploads/2021/03/qsir-sbar-communication-tool.pdf" target="_blank">“Online library of Quality, Service Improvement and Redesign tools” </a></td></tr></tbody></table><br /></p><p>There are benefits to using some sort of mnemonic that all parties involved in a communication are familiar with. It reduces unnecessary questions, structures the information and suggests a minimum dataset that the caller should be able to relay.</p><p>There are significant downsides to SBAR.</p><p>First, nobody actually uses it (or if they do, they don’t use it in simulation). Everybody talks about it, everybody refers to it, people say that’s what they use, but they don’t. People use RAB, ABR, ABS and all sorts of other methods for conveying information.</p><p>Second, it’s not what the receiver wants to hear. In particular, the receiver does not want to wait however many minutes it takes to get to the R. The receiver wants to hear the R up front because then they know if they need to get out of bed, get someone else to take over the patient they’re dealing with, sit back to listen to the rest of the story to provide advice, etc.</p><p>Third, the SBAR does not confirm accurate receipt of the information. (In the picture above this is suggested at the bottom of the SBAR tool).</p><p>Fourth, the SBAR has become so engrained within healthcare that it will be difficult replace it even though it is a poor cognitive aid. </p><p>There is a better mnemonic, it is called <a href="https://staging.mja.com.au/system/files/issues/190_11_010609/con11210_fm.pdf" target="_blank">ISOBAR</a>. </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhDAxghGq_-JaYz_QJ3299DHqXMke_4AXTKe5dVAYCghf4snPF3O2PZLaiteu_qOyguiCAxtZ3h3ZhbZms6OXzcNwMzDqXAe9EisN8d6uSxXIGndSAq5SsuFp214k5OJRCP_pQ-woBeniRsmYiwDD-4nMrZD97oqsIGh5X3n1XMGOZ8Uan7_UXMuW9M/s812/836F9190-0745-4058-AEB3-215C47BD525E.jpeg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="471" data-original-width="812" height="233" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhDAxghGq_-JaYz_QJ3299DHqXMke_4AXTKe5dVAYCghf4snPF3O2PZLaiteu_qOyguiCAxtZ3h3ZhbZms6OXzcNwMzDqXAe9EisN8d6uSxXIGndSAq5SsuFp214k5OJRCP_pQ-woBeniRsmYiwDD-4nMrZD97oqsIGh5X3n1XMGOZ8Uan7_UXMuW9M/w400-h233/836F9190-0745-4058-AEB3-215C47BD525E.jpeg" width="400" /></a></div><div class="separator" style="clear: both; text-align: center;">From Porteous et al. “<span style="text-align: left;"> iSoBAR — a concept and handover checklist: </span></div><div class="separator" style="clear: both; text-align: center;"><span style="text-align: left;">the National Clinical Handover Initiative”</span></div><br /><p></p><p>ISOBAR includes identifying yourself and the patient, and a read back at the end. (The A has been changed from Assessment to Agreed Plan.) Now, if we just make it that little bit better by adding another R (for “Reason for calling” perhaps) and taking away the B, we would get IRSOAR (eye-arr-soar). </p><blockquote style="border: none; margin: 0 0 0 40px; padding: 0px;"><blockquote style="border: none; margin: 0 0 0 40px; padding: 0px;"><blockquote style="border: none; margin: 0 0 0 40px; padding: 0px;"><p style="text-align: left;"></p></blockquote></blockquote></blockquote><div><br /></div><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgOuB3Xs6IYmR_7KJWdtdYo4EVEnrCzSGzmxulUqkbI-sR27cCiEtpg5XHzK0nq9gShRdChUkqd3xb7vzxBMMMqyty2gM1tVo5c1K6h0b7ZFGI5TWdui2Z8aH6LhvUZAER7IdaA9wTPQom2T-Me9iD8VE2LALeQf10OzlumJn354l29-QvDBIKQp0x4/s1605/9B0B5006-79DA-406D-A573-5901EF045148.jpeg" imageanchor="1" style="margin-left: 1em; margin-right: 1em; text-align: center;"><img border="0" data-original-height="502" data-original-width="1605" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgOuB3Xs6IYmR_7KJWdtdYo4EVEnrCzSGzmxulUqkbI-sR27cCiEtpg5XHzK0nq9gShRdChUkqd3xb7vzxBMMMqyty2gM1tVo5c1K6h0b7ZFGI5TWdui2Z8aH6LhvUZAER7IdaA9wTPQom2T-Me9iD8VE2LALeQf10OzlumJn354l29-QvDBIKQp0x4/w640-h200/9B0B5006-79DA-406D-A573-5901EF045148.jpeg" width="640" /></a><div><p>It’s not quite as catchy as SBAR. It just about squeezes in to the “magic number 7” rule. But if it could overcome those barriers it would be a tool that might actually be used and useful.</p><div class="separator" style="clear: both; text-align: center;"><br /></div><br /></div>Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com0tag:blogger.com,1999:blog-3508305836023632036.post-8952771983126868472018-06-19T20:19:00.001+01:002018-06-19T20:19:25.639+01:00The A word<br />
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In a recent <a href="http://simulatinghealthcare.net/2018/05/08/dont-be-confused-every-simulation-is-an-assessment/" target="_blank">blogpost</a> Paul Phrampus argued that we should not shy away from the word “assessment” in simulation. He states: “...every simulation is an assessment!”</div>
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Words shape our world. We communicate through the words we use, to relay information and influence people. The words we use also tell listeners about us, think of “economic migrants”, “illegal aliens” and “hostile environment”. Lastly, our vocabulary has a direct effect on our thinking; if we don’t know the words and their definitions it is difficult to think rationally about a subject.</div>
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Assessment</h3>
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The word evokes feelings of stress. It is synonymous with judgment, passing and failing, a dispassionate observer providing an objective grade based on performance.</div>
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Some try to soften the word (formative assessment) or its synonyms (good judgment). Yet the people being assessed are unlikely to be reassured.</div>
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I would like to offer an alternative: “Analysis” Why not stop assessing people’s performance and start analysing it? The word evokes less stress and does not suggest judgment, but rather a review of what happened. For those who like modifiers perhaps “gap analysis” would work. The observer’s role is to look for the gaps in performance.</div>
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If we are analysing we are not assessing. We can be open and clear about what the goals of the scenario and debrief are. And we can remind ourselves that, in the end, it does not matter what we think the performance gaps were. What matters is that we have, through analysis and conversation, facilitated the realisation of these gaps in our learners. Moving from assessment to analysis may also help with another common problem that Paul has identified:</div>
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Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com2tag:blogger.com,1999:blog-3508305836023632036.post-45051870190183245392018-04-30T22:27:00.001+01:002018-04-30T22:27:06.522+01:00Book of the month: Human Factors & Ergonomics in Practice (by Steven Shorrock & Claire Williams (eds))<div class="separator" style="clear: both; text-align: center;">
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(Conflict of interest:<span style="font-weight: normal;"> I have had a number of chats with Steven Shorrock, as well as email & twitter correspondence, and ran a 1-day Human Factors for Surgeons course with him. I have tried to give an objective review.)</span></div>
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<span style="background-color: rgba(255, 255, 255, 0);">About the editors</span></div>
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<span style="font-weight: normal;">Steven Shorrock BSc, MSc, PhD (</span><a href="https://twitter.com/StevenShorrock" style="font-weight: normal;" target="_blank">@StevenShorrock</a><span style="font-weight: normal;">) is a chartered ergonomist and human factors specialist and a chartered psychologist. He is the European safety culture program leader at EUROCONTROL and adjunct senior lecturer at the School of Aviation, University of New South Wales, Sydney, Australia.</span><br />
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<span style="font-weight: normal;">Claire Williams BSc, MSc, PhD (<a href="https://twitter.com/claire_dr" target="_blank">@claire_dr</a>) </span><span style="background-color: rgba(255, 255, 255, 0); font-weight: normal;">is a chartered ergonomist and human factors specialist. She is a senior HF/E consultant at <a href="https://www.humanapps.co.uk/" target="_blank">Human Applications</a> and visiting research fellow in HF and behaviour change at Derby University, Derby, UK.</span><br />
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About the contributors</h4>
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There are 45 other contributors, including internationally-recognised names such as Ken Catchpole, Sidney Dekker, Erik Hollnagel and Martin Bromiley. The contributors are based in North America, Europe and Australia. As befits the title, they are mainly involved in applied, practical human factors ergonomics.</div>
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Who should read this book?</h4>
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This book should be on the bookshelf (actual or digital) of all those who are involved in HF/E work. This includes the "HF/E curious" with no formal qualifications in HF/E, experienced chartered ergonomists, as well as those who are purchasing the skills of HF/E practitioners. The book will also resonate with simulation-based educators with a number of themes such as safety culture and HF/E in healthcare.</div>
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<span style="font-weight: normal;">The book is divided into 4 parts (31 chapters), as well as a foreword and afterword.</span></div>
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<span style="font-weight: normal;">Part 1, "Reflections on the Profession", considers the definition of HF/E, as well as its history and current practice. </span><br />
<span style="font-weight: normal;">Part 2, "Fundamental Issues for Practitioners", looks at some of roles HF/E specialists have to adopt and the challenges they face. These challenges include carrying out research when the employer is looking for a practical solution or the information gathered could be sensitive or embarrassing.</span><br />
<span style="font-weight: normal;">Part 3, "Domain-specific issues", details the musings of specialists currently engaged in a number of different domains. These include "obvious" sectors such as aviation, oil and gas exploration, and the nuclear industry, as well as less well-known sectors such as web engineering, agriculture, and the construction and demolition industry.</span><br />
<span style="font-weight: normal;">Part 4, "Communicating about Human Factors and Ergonomics", explains how to engage with executives as well as those at the sharp end.</span><br />
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">I haven't got the time to read 413 pages...</span></h4>
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Each Part has its own summary to give you an idea about what is going to be discussed and, as should be the norm with edited books, every chapter also starts with a single paragraph practitioner summary. You can therefore decide which chapters are most likely to be of benefit to you (although see "What's good about this book?" below)<br />
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<span style="font-weight: normal;">There is a degree of soul-searching here not often seen in textbooks. For example, in Chapter 5 "Human Factors and the Ethics of Explaining Failure”, van Winsen and Dekker refer to the case of Karl Lilgert. Karl was jailed after the ferry he was in charge of, the “Queen of the North”, sank in 2006. In their verdict, the Supreme Court of British Columbia stated: “Maintaining situational awareness at all times and in all circumstances is key to proper navigation.” Situational awareness (SA) is a construct which HF/E practitioners (and others) use to explain human behavior. When terms such as SA are (mis)used by the legal profession then how much responsibility do HF/E practitioners bear? Similar arguments around the use of terms can be made regarding the use of “human error”. Although HF/E practitioners might know what they mean when they say “x% of accidents are due to human error”, the media and public often do not (p.87).</span><br />
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<span style="font-weight: normal;">The book also reflects on the tension between the HF/E practitioners who work in research/academia and those who work in industry, as well as the place for those who are not formally qualified in HF/E. As with all professions, each group has different priorities, ways of working and cultures. In Chapter 1, Shorrock and Williams argue for a middle ground in which there is “collaboration among those with expertise in theory, method, and aspects of context… and those with deep expertise in their jobs, working environments, and industry” (p.14).</span><br />
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<span style="font-weight: normal;">Hollnagel’s chapter on “The Nitty-Gritty of Human Factors” (p.45-62) is a good read. He talks about a pragmatic approach to human factors and counsels caution when using constructs such as “short term memory”. He advises us to remember that these constructs have been created to explain some observations but that they are constructs, with limitations.</span><br />
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<span style="font-weight: normal;">Although healthcare workers might not be immediately drawn to a chapter entitled “Becoming a Human Factors/Ergonomics Practitioner” (Chapter 12), this chapter is worth a read for those of us involved in simulation and education. This chapter explores a number of challenges faced by those who want to certify as HF/E practitioners, as well as those who run the courses which lead to certification. In particular, there is a sense that the courses provide graduates with knowledge but perhaps not the skills required to enter the workplace. A similar problem is seen in healthcare where nurses graduate with the skills required to do the job from the first day whereas doctors often have a significant amount of “on the job” learning to do. This inability to perform Miller's "shows how" and "does" is something that we can use simulation-based education to address.</span><br />
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<span style="font-weight: normal;">Healthcare practitioners and HF/E workers involved in healthcare must read Chapter 13 “Human Factors and Ergonomics Practice in Healthcare”. This details some of the issues that affect HF/E work in healthcare including the proliferation of checklists and the “try harder” mentality. Shelly Jeffcott (<a href="https://twitter.com/drjeffcott" target="_blank">@drjeffcott</a>) and Ken Catchpole (<a href="https://twitter.com/KenCatchpole" target="_blank">@KenCatchpole</a>) are rightly optimistic about the future of HF/E in the healthcare setting. Simulation-based educators will also be pleased to see reference to simulation in design and procurement (p.189)</span></div>
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<span style="font-weight: normal;">The authors explain why we should be adopting a Safety-II approach, spend more time looking at the system than at the person and appreciate that the system is complex and intractable. However, there is a dearth of information about what to practically do. When an avoidable death occurs in healthcare (or other industries) there is little chance that bereaved families would be satisfied with explanations of complex systems, etc. It would be useful for the reader of “HF/E in Practice” to be given an introduction to current methods in HF/E and their uses.</span></h4>
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<span style="font-weight: normal;">This is the best book I have read on Human Factors/Ergonomics. Its focus on the applied, practical aspects of HF/E make it relevant to front-line workers as well managers and researchers. If the General Medical Council is serious about wanting to involve HF/E professionals in its work then council members would do well to read this book.</span></div>
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Further reading:</h4>
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<a href="http://safetydifferently.com/">safetydifferently.com</a><br />
<a href="http://chfg.org/">chfg.org</a><br />
<a href="http://ergonomics.org.uk/">ergonomics.org.uk</a></div>
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Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com0tag:blogger.com,1999:blog-3508305836023632036.post-71838615082486668102018-04-22T14:58:00.003+01:002018-04-22T15:00:22.719+01:00Making Care Better: Lessons from Space<div align="center" class="MsoNormal" style="background: #DEEAF6; mso-background-themecolor: accent1; mso-background-themetint: 51; text-align: center;">
<a href="http://www.healthcareimprovementscotland.org/our_work/clinical_engagement/qi_connect.aspx"><span style="mso-bidi-font-family: Arial;">Healthcare Improvement Scotland</span></a><span style="mso-bidi-font-family: Arial;"> supports continuous improvement in health
care and social care practice and this event is part of their </span><a href="http://www.healthcareimprovementscotland.org/our_work/clinical_engagement/qi_connect.aspx"><span style="mso-bidi-font-family: Arial;">QI Connect WebEx series</span></a><span style="mso-bidi-font-family: Arial;"> connecting health and care professionals
with improvement expertise from all over the world.<o:p></o:p></span></div>
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<span style="mso-bidi-font-family: Arial;">This event took place on 8 November at the
Planetarium within the Glasgow Science Centre, with more than 120 health and
social care colleagues in attendance and many more attending virtually by
WebEx.<o:p></o:p></span></div>
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<i style="mso-bidi-font-style: normal;"><span style="mso-spacerun: yes;"> </span>“This is always a difficult presentation for
me, but it is one of hope. The hope is that the people who hear it will tell
the story and spread the word. The similarities in what we did, in terms of
understanding, mitigating and minimising risk is as much as part of your
everyday job in caring for your patients, as it is mine. To me, I owe it to the
next generation of people who climb into the next space craft. I don’t want
them to end up in the same situation as my friends, </i><i style="mso-bidi-font-style: normal;">the crew of Space
Shuttle Columbia.”</i></div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgGoFK_WfMfn1X-CVnMCyutzvj4cK49DsMfMk1WWIkLOwjy35K9z7GjMV2LDRiKqx3YTIwYoceKMBFyfKpgLVEBYMvjcPaCu-41gB51JID99nGBlJb3VI3HxCe-mmQv4AiI-2MfoAhJMog/s1600/NASADrNigelPackham+4.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1065" data-original-width="1600" height="213" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgGoFK_WfMfn1X-CVnMCyutzvj4cK49DsMfMk1WWIkLOwjy35K9z7GjMV2LDRiKqx3YTIwYoceKMBFyfKpgLVEBYMvjcPaCu-41gB51JID99nGBlJb3VI3HxCe-mmQv4AiI-2MfoAhJMog/s320/NASADrNigelPackham+4.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Dr Nigel Packham</td></tr>
</tbody></table>
Born in
London and now living in Houston, Texas, <a href="https://www.nasa.gov/offices/oce/pmchallenge/sessions/Nigel-Packham-Bio.html">Dr
Nigel Packham</a> is no stranger to the world of healthcare. Both his parents
were clinicians: his father an Urologist and his mother an Ophthalmologist. His
brother, a recently retired General Physician. Nigel, himself, works at NASA
Johnson Space Centre as lead for flight safety and managed the review which led
to the public release of the <a href="https://www.nasa.gov/pdf/298870main_SP-2008-565.pdf">Columbia Crew
Survival Investigation Report</a> in 2008.<o:p></o:p><br />
<br /></div>
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On 16<sup>th</sup>
January 2003, Space Shuttle Columbia (STS-107) embarked on her 28<sup>th</sup>
orbital flight which was to be a 16 day science mission. At 81.7 seconds into
the flight, a piece of foam detached from the external fuel tank and collided
with the left wing of Columbia causing significant damage. Whilst in space,
Columbia was able to perform what appeared to be as normal and the crew of
seven completed their scheduled experiments successfully and without any cause
for concern.</div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm;">
<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm;">
On 1
February 2003, Columbia deorbited and reached the entry interface to the
Earth’s atmosphere (around 400,000 feet in altitude) travelling at 24.5 times
the speed of sound. The planned touchdown at the Kennedy Space Centre, Florida,
was at 14.15 pm GMT. At 13.58pm GMT, Mission Control reported an issue with the
inboard tyre pressure on the left side of the Shuttle and by 13.59 pm GMT, they
had lost communication with the crew. <o:p></o:p><br />
<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm;">
<b style="mso-bidi-font-weight: normal;">“In the space of 10 seconds we went from
being in control to being out of control.”<o:p></o:p></b></div>
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<br /></div>
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<span style="mso-fareast-font-family: "Times New Roman";">The tragedy of the last
moments prior to the disintegration of Space Shuttle Columbia was graphically
shown through different perspectives. Through those watching on the ground; a
video simulation depicting a vehicle out of control; and the impending disaster
through the eyes of the crew who bravely battled to re-gain control.<span style="mso-spacerun: yes;"> </span> <o:p></o:p></span></div>
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<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm;">
<span style="mso-fareast-font-family: "Times New Roman";">Each of these perspectives
show the same tragic events unfolding but from different viewpoints. The story
of NASA’s learning from the Columbia disaster has learning for health and
social care. <o:p></o:p></span></div>
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<b>Is it safe?<o:p></o:p></b></div>
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The simple
fact, as Nigel explains is that space travel is not without risk and, as in
health and social care, we need to, instead, ask the question: ‘is it safe
enough?’ How we manage risk is key. We must identify and understand the
likelihood of any risk and mitigate to minimise the potential impact. <b><o:p></o:p></b></div>
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But, who ultimately
accepts these risks? In space travel, this would, of course, be the astronauts
themselves. Within health and social care, we have a responsibility to ensure
that people are supported to make an informed decision about their own care and
understand the risks they are ultimately facing. The principles of ‘<a href="http://www.gov.scot/Resource/0049/00492520.pdf">Realistic Medicine</a>’
now apply, not only globally, but also universally.<o:p></o:p></div>
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<br /></div>
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The consideration and
interpretation of risk changes with the accumulation of knowledge. The risk of
a disaster at the outset of the Space Shuttle Programme in 1981 was estimated
between 1:1,000 and 1:10,000. By the time of the completion of Shuttle
Programme in 2011, 135 flights later, the modern tools estimated the risk for
the first flight was revised to 1:12. New data and the accumulation of
learning made NASA radically re assess their quantification of the risks of
space travel. <o:p></o:p></div>
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<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm;">
So what about health and
social care? How should we systematically interpret our perception of risk
based on our experience of incidents, both locally and nationally? How do we
share our knowledge and learning so that we can prevent further
tragedies? <o:p></o:p><br />
<br /></div>
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<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm;">
<b>“These
were our friends"<o:p></o:p></b></div>
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<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm;">
Following the Columbia
disaster, NASA has carefully considered its culture and leadership model. Their
decision to publically share the final investigation report would, in no doubt,
have been a difficult one, due to the sensitivities for the families and loved
ones of the crew but, also, for NASA staff who were responsible for guiding the
Shuttle safely back to Earth. <o:p></o:p></div>
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<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm;">
As part of their commitment
to continuous improvement, NASA now routinely collect and share examples of real
and potential adverse events at different stages - from blast off, to orbit,
re-entry, and landing. Each stage is described as well as the implications for
improved and ultimately safer systems. Sharing this internally to improve their
own safety procedures is one thing, but NASA goes a step further by pro-actively sharing with other
space faring nations so that they can also learn and avoid making similar
mistakes. <o:p></o:p></div>
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<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm;">
Ensuring that we too create a
culture within health and social care which supports openness and learning is
essential so that we can continue to make care better. The events in Mid
Staffordshire NHS Trust highlighted the fundamental difference in perspectives
of the Trust Board, the regulators who oversaw that Trust, the staff and those
families caring for their loved ones. The voices of the weakest - the junior
doctors and the families - were not heard until it was too late. From the bed
side to the board room, there was a deep and fundamental failure to listen and
to act.<o:p></o:p><br />
<br /></div>
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<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm;">
<b>Lessons
for Healthcare</b></div>
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<br /></div>
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<span style="font-family: inherit;">There is much that we can
learn from NASA as well as other high risk and high reliable organisations.
Specifically, how they have continued to develop processes to support learning
and improvement following close calls or poor outcomes. Though there are
inherent differences between health care and space flight, it is evident that
success in outcomes in both these fields is ultimately dependent on the
interaction between systems, people and environment. <o:p></o:p></span></div>
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<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm;">
<span style="font-family: inherit;">The key is to have a better
understanding of these interactions within a complex systems and its relevance
when things do go wrong. Often when reviews of ‘incidents’ or adverse events
are performed in healthcare, there can exist disconnect between reviewers and
individuals or teams involved with the care of the patient. This includes
differences in understanding of the challenges faced at the various levels
within the overall system meant to support provision of good care. Feedback from
reviews may be delayed or even not shared. This highlights the significance of the
concept of Work-As-Imagined versus Work-as-Done in healthcare which often
contributes to constraints in conducting effective reviews. This inevitably
leads to a lost opportunity in understanding weaknesses within the system,
possible incorrect focus on what is deemed to be the required improvements as
well as in difficulty in capturing and sharing learning.<o:p></o:p></span></div>
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<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm;">
<span style="font-family: inherit;">We believe a significant
opportunity does already exist in health care to address these challenges and
we are working on <a href="http://ihub.scot/scottish-mortality-and-morbidity/" target="_blank">optimising this process for NHS Scotland</a>.
Mortality and Morbidity Review (M&M)
or similar peer review meetings and process describes a systematic
approach that provides members of a healthcare team with the opportunity for
timely peer review of complaints, adverse events, complications or mortality.
This facilitates reflection, learning and improvement in patient care.
Importantly, such peer review processes also provide the opportunity to explore
and inquire the significant majority of good practice that occurs daily in
patient care.<o:p></o:p></span></div>
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<br /></div>
<div class="BodyText1">
<span style="font-family: inherit;">When carried out well, structured M&Ms have added advantages compared
to other review processes, including being as near to the event or patient
experience as possible and helps promote a culture which support openness and
learning in organisations. It provides an opportunity for teams to seek
multiple perspectives, describe and discuss complex systems issues and
interactions which may have contributed to the event. These factors can be
missed when carrying out case note reviews or audits of care. M&Ms also
facilitate sharing of learning and immediate feedback, ensuring concerns are
addressed immediately thus helping mitigate against errors recurring whilst a
relatively lengthy review process is undertaken. This process brings Work- As-
Imagined and Work-As-Done closer and provides an opportunity for a better
understanding of risks and sharing of learning from frontline to board to improve
care.</span><span style="font-family: "calibri";"><o:p></o:p></span></div>
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<b>Authors:</b></div>
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<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgXwtF1w_kIOriKQT4HR80vtdfc7C_N0Gb_xKdAi1nNHeeXyOAvOrBcq29WabIajvX2Mz4tAsYBN8l6vqEWSAwjBHfa-aNDCroeNqUxgCdCoEDqk1Tx4wOYVdQ5xODwmJ9LxKbdo6w6v14/s1600/NASADrNigelPackham+19.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1065" data-original-width="1600" height="213" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgXwtF1w_kIOriKQT4HR80vtdfc7C_N0Gb_xKdAi1nNHeeXyOAvOrBcq29WabIajvX2Mz4tAsYBN8l6vqEWSAwjBHfa-aNDCroeNqUxgCdCoEDqk1Tx4wOYVdQ5xODwmJ9LxKbdo6w6v14/s320/NASADrNigelPackham+19.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Jennifer, Nigel and Manoj</td></tr>
</tbody></table>
Manoj Kumar, National Clinical Lead, Scottish Mortality & Morbidity Programme, Healthcare Improvement Scotland / Consultant General Surgeon, NHS Grampian <a href="https://twitter.com/Manoj_K_Kumar">@Manoj_K_Kumar</a></div>
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<br /></div>
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Robbie Pearson, Chief Executive, Healthcare Improvement Scotland <a href="https://twitter.com/rpearson1969">@rpearson1969</a></div>
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<br /></div>
<div class="msocomtxt" id="_com_1" language="JavaScript">
Jennifer Graham, Clinical Programme Manager, Healthcare Improvement Scotland <a href="https://twitter.com/jennigraham8">@jennigraham8</a><br />
<br />
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Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com0tag:blogger.com,1999:blog-3508305836023632036.post-84535186144319855872017-09-07T09:50:00.000+01:002017-09-07T09:50:39.757+01:00What's in your attic?<div>
<div class="p1" style="color: #454545; font-family: '.SF UI Text'; font-size: 17px; line-height: normal;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhXzVyzqSW1jzn0HELi3dbU6OD2CDNiStQziCFYWo5sCvPAQaQKz_OunGcdWrZLs02_jKF5QyvJ__If8STwjV4z6LF5bkC7YzjtlZCqssAMuhiJvJagrAe4OtH8TEXyGm0L6RkSQUhlv_8/s1600/IMG_9247.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="198" data-original-width="360" height="110" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhXzVyzqSW1jzn0HELi3dbU6OD2CDNiStQziCFYWo5sCvPAQaQKz_OunGcdWrZLs02_jKF5QyvJ__If8STwjV4z6LF5bkC7YzjtlZCqssAMuhiJvJagrAe4OtH8TEXyGm0L6RkSQUhlv_8/s200/IMG_9247.jpg" width="200" /></a><span style="font-family: ".sfuitext"; font-size: 17pt;">This blogpost weaves together 4 threads:</span></div>
<div class="p2" style="color: #454545; font-family: '.SF UI Text'; font-size: 17px; line-height: normal; min-height: 20.3px;">
<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;"></span></div>
<div class="p2" style="color: #454545; font-family: '.SF UI Text'; font-size: 17px; line-height: normal; min-height: 20.3px;">
<span style="font-family: ".sfuitext"; font-size: 17pt;">1) In Oscar Wilde's only novel, "The Picture of Dorian Gray", Dorian sells his soul to ensure that a portrait of him ages while he remains young. </span><span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;"></span></div>
<div class="p2" style="color: #454545; font-family: '.SF UI Text'; font-size: 17px; line-height: normal; min-height: 20.3px;">
<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;"></span><br /></div>
<div class="p1" style="color: #454545; font-family: '.SF UI Text'; font-size: 17px; line-height: normal;">
<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;">2) In his must-read book "Safe Patients, Smart Hospitals" Peter Pronovost argues that healthcare professionals are very good at hiding mistakes from themselves. They compartmentalise mistakes and explain them away because of a belief that "doctors don't make mistakes."</span></div>
<div class="p2" style="color: #454545; font-family: '.SF UI Text'; font-size: 17px; line-height: normal; min-height: 20.3px;">
<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;"></span><br /></div>
<div class="p1" style="line-height: normal;">
<div style="color: #454545; font-family: '.sf ui text'; font-size: 17px;">
<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;">3) In a <a href="https://www.ccescotland.com/past-events" target="_blank">very good lecture</a>, Scott Weingart argues that:</span></div>
<div style="color: #454545; font-family: '.sf ui text'; font-size: 17px;">
<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;"><br /></span></div>
<span class="s1" style="color: #454545; font-family: "sfuitext"; font-size: 22.66666603088379px;">"The difference between bad doctors and good doctors is not that the bad ones make a bad decision every single shift or even every single week. The difference between a bad doctor and a good doctor may be one bad decision a month. And that's really hard to get self-realised feedback on. There are not enough occurrences of real, objective badness to learn from one's mistakes."</span></div>
<div class="p2" style="color: #454545; font-family: '.SF UI Text'; font-size: 17px; line-height: normal; min-height: 20.3px;">
<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;"></span><br /></div>
<div class="p1" style="color: #454545; font-family: '.SF UI Text'; font-size: 17px; line-height: normal;">
<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;">4) Lastly, if we take the numbers from the Instititute of Medicine's "To Err is Human" as correct then we can postulate the following: </span></div>
<div class="p1" style="line-height: normal;">
</div>
<ul>
<li style="color: #454545; font-family: '.SF UI Text'; font-size: 17px;"><span style="font-family: ".sfuitext"; font-size: 17pt;">There are approximately 100,000 deaths due to medical error per year in the US (1)</span></li>
<li style="color: #454545; font-family: '.SF UI Text'; font-size: 17px;"><span style="font-family: ".sfuitext"; font-size: 17pt;">There are approximately 500,000 doctors in the US (2)</span></li>
<li style="color: #454545; font-family: '.SF UI Text'; font-size: 17px;"><span style="font-family: ".sfuitext"; font-size: 17pt;">Therefore a given doctor will be involved in a death due to medical error once every 5 years</span></li>
<li style="color: #454545; font-family: '.SF UI Text'; font-size: 17px;"><span style="color: #454545; font-family: .sfuitext;"><span style="font-size: 22.66666603088379px;">Let us make the assumption that only 50% of these deaths are recognised as having been caused by medical error. Then a given doctor will be aware of a patient who died in part due to his/her medical error once every 10 years. Or 4 deaths per career.</span></span></li>
</ul>
</div>
<br />
<div class="p1" style="color: #454545; font-family: '.SF UI Text'; font-size: 17px; line-height: normal;">
<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;">Now for the weaving. </span><br />
<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;"><br /></span>
<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;">For a number of reasons healthcare professionals will not be able to have a good understanding of their actual performance. Partly this is because our involvement in errors leading to death is (thankfully) rare and partly because the feedback loop in healthcare is often very long or non-existent. </span><br />
<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;"><br /></span>
<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;">We are also, because we are human, very good at rationalising our poor performance. Lastly many of our jobs require confidence, or at least an outward confidence, in order to believe that we can do the job and to put patients at ease. </span></div>
<div class="p2" style="color: #454545; font-family: '.SF UI Text'; font-size: 17px; line-height: normal; min-height: 20.3px;">
<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;"></span><br /></div>
<div class="p1" style="color: #454545; font-family: '.SF UI Text'; font-size: 17px; line-height: normal;">
<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;">This means that, like Dorian Grey, we have a public persona which is confident, capable and error-free. But we also have our "true" selves hidden away, perhaps not as pretty as we might like to think. </span></div>
<div class="p2" style="color: #454545; font-family: '.SF UI Text'; font-size: 17px; line-height: normal; min-height: 20.3px;">
<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;"></span><br /></div>
<div class="p1" style="color: #454545; font-family: '.SF UI Text'; font-size: 17px; line-height: normal;">
<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;">If this is a problem then what are the solutions? </span><br />
<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;"><br /></span>
<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;">Unsurprisingly perhaps, given that this is a simulation & HF blog, one solution is immersive simulation. The simulation has to be realistic enough to trigger "natural" behaviour and actions. Realisation of the differences between one's imagined and actual performance <span class="Apple-converted-space"> </span>often emerge as the simulation progresses. The simulation can also create the conditions under which poor decisions are more likely to be made. This means rather than waiting a month for a sufficiently stressful real-life event to occur, twelve stressful scenarios can be created in a day.</span><br />
<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;"><br /></span>
<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;">However it is during the debrief that the two personas, the portrait and the person, can be compared. The use of video-based debriefing means that the participant can see their own performance from an outsider's perspective. The facilitator helps the participant see the metaphorical wrinkles and scars that have accumulated over time. The skilled facilitator provides help in taking ownership of the blemishes and advice on how to work on reducing them.</span></div>
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<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;"></span><br /></div>
<div class="p1" style="color: #454545; font-family: '.SF UI Text'; font-size: 17px; line-height: normal;">
<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;">Simulation remains overwhelmingly the domain of the healthcare professional "in training". Consultants, staff grades, registered nurses, midwives and other fully qualified professionals rarely cross the threshold. Perhaps this is because in training the portrait of ones true self is constantly being exposed. It hangs, as it were, above the fireplace or in a prominent position where many people can and do comment on it. Upon completion of training it is with a sense of relief that the portrait is relocated to the attic. And the longer it stays up there, the greater the fear of the horror we will be faced with if we take it back down.</span></div>
<div class="p2" style="color: #454545; font-family: '.SF UI Text'; font-size: 17px; line-height: normal; min-height: 20.3px;">
<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;"></span><br /></div>
<div class="p1" style="color: #454545; font-family: '.SF UI Text'; font-size: 17px; line-height: normal;">
<span class="s1" style="font-family: ".sfuitext"; font-size: 17pt;">Face your fears, attend a simulation session and let's clear out that attic together. </span></div>
<br />
References:<br />
1) DONALDSON, M. S., CORRIGAN, J. M. & KOHN, L. T. 2000. To err is human: building a safer health system, National Academies Press.<br />
2) Number of active physicians in the U.S. in 2017, by specialty area (Accessed 7/9/17) https://www.statista.com/statistics/209424/us-number-of-active-physicians-by-specialty-area/<br />
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</span></span></span></span></span></div>
Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com1tag:blogger.com,1999:blog-3508305836023632036.post-32079779461644209452017-04-17T13:03:00.002+01:002017-04-17T13:08:30.997+01:00Translating simulation into clinical practice: Psychological safety<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
At our
sim centre, safety is a key concern. When people mention safety in the context
of simulation, the first thought is often the safety of the patient. Simulation
is safe for patients because, in the majority of cases, lack of patient
involvement means that no patient is harmed. Perhaps the second thought
regarding patient safety is that this is one of the reasons we carry out
simulation in the first place.</div>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
<o:p></o:p></div>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
<br /></div>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
Safety
is not just about the patient however, but also about the simulation
participant. In terms of physical safety, at our sim centre we have had sharps
injuries, slips and trips, as well as a defibrillation of a mannequin while CPR
was in progress. So, physical safety is important.<o:p></o:p></div>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
<br /></div>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
However,
we think that the psychological safety of the participants is as important as
their physical safety. Psychological safety “describes perceptions of the
consequences of taking interpersonal risks in a particular context such as a
workplace” (Edmondson & Lei 2014).<span style="mso-spacerun: yes;">
</span>When people feel psychologically safe they will be more willing to speak
up, to share their thoughts, and to admit personal limitations. This means that
psychological safety is important not just in simulations but also in clinical
practice.<o:p></o:p></div>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
<br /></div>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
The
psychologically safe simulation environment is not self-generating, it must be
created and sustained by the facilitator and participants. Creating this
environment is not a cryptic, mystical feat which is only achieved by the
expert few, but rather a set of behaviours and actions which can be learned.
This means that the lessons learnt from creating psychological safety in
simulation can be translated into clinical practice. Key concepts are:</div>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
</div>
<ul>
<li><span style="text-indent: -18pt;">Flatten the hierarchy</span></li>
<li><span style="text-indent: -18pt;">Prime people that mistakes will be made</span></li>
<li><span style="text-indent: -18pt;">Set an expectation of challenging observable
behaviours/actions</span></li>
<li><span style="text-indent: -18pt;">Stress confidentiality</span></li>
</ul>
<br />
<ul>
</ul>
<h4>
Flatten
the hierarchy</h4>
<br />
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
A
hierarchy is evidenced by a power distance or authority gradient where certain
people are placed “above” others usually as a result of additional training or
skills. A hierarchy, with defined leadership, is essential for safe care.
However when the authority gradient is very steep those lower down are less
likely to challenge behaviour. In aviation this has contributed to a number of
well-publicised crashes including the Tenerife disaster. In healthcare it
results in leaders making fatal (for the patient) mistakes without members of
their team speaking up to correct them.</div>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
<o:p></o:p></div>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
<br /></div>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
Flatten
the hierarchy:<o:p></o:p></div>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
<span style="mso-tab-count: 1;"> </span>In the daily brief by:<o:p></o:p></div>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
<span style="mso-tab-count: 1;"> </span>Ensuring everyone introduces
themselves<o:p></o:p></div>
<div class="MsoNormal" style="text-align: justify; text-indent: 36.0pt; text-justify: inter-ideograph;">
Ensuring everyone introduces themeselves by their first
name<o:p></o:p></div>
<div class="MsoNormal" style="text-align: justify; text-indent: 36.0pt; text-justify: inter-ideograph;">
Admitting to personal fallibility<o:p></o:p></div>
<div class="MsoNormal" style="text-align: justify; text-indent: 36.0pt; text-justify: inter-ideograph;">
Setting the tone of expected respect<o:p></o:p></div>
<div class="MsoNormal" style="text-align: justify; text-indent: 36.0pt; text-justify: inter-ideograph;">
<br /></div>
<div class="MsoNormal" style="text-align: justify; text-indent: 36.0pt; text-justify: inter-ideograph;">
During the day by:<o:p></o:p></div>
<div class="MsoNormal" style="margin-left: 36.0pt; text-align: justify; text-justify: inter-ideograph;">
Gently correcting colleagues who use your title to refer to
you by first name<o:p></o:p></div>
<div class="MsoNormal" style="margin-left: 36.0pt; text-align: justify; text-justify: inter-ideograph;">
Protecting those at the bottom of the authority gradient from
bullying, harassment or other demeaning behaviour by others.<o:p></o:p></div>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
<br /></div>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
<br /></div>
<h4>
Prime
people that mistakes will be made</h4>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
<o:p></o:p></div>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
In
the simulated environment mistakes are almost guaranteed due to the planned crisis
nature of the experience. In clinical practice mistakes cannot be guaranteed
but it is unlikely that no mistakes will happen during a typical day. (Where
research has been carried out, in paediatric cardiac surgery, there were
approximately 2 major compensated events and 9 minor compensated events per
operation. (Galvan et al, 2005)) It is therefore essential to prime people at
the beginning of the day that mistakes are likely, that this is “normal” and
that they should be looking out for them.<o:p></o:p></div>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
<br /></div>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
<br /></div>
<h4>
Set
an expectation of respectful challenge to observable behaviours/actions</h4>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
<o:p></o:p></div>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
You have made it clear that people will make mistakes. You can then therefore set an
expectation that others will challenge any behaviour or action which they are
unsure about, which they think is a mistake or which they think threatens
patient safety. Warn people that when their behaviour or action is under scrutiny that they will feel uncomfortable and perhaps threatened. Reassure people that when they are having these feelings of discomfort that they are experiencing a "learning moment". Either the person raising the concern is correct and a mistake is being averted or they are correct and the person raising the concern can be thanked and the action clarified.<br />
<br />
<h4>
Stress confidentiality</h4>
In the simulation environment, with very few exceptions, we can guarantee that the experience will remain confidential with respect to the facilitator (i.e. we will not talk about participant performance after the simulated event is over) and that we expect the same from the participants. In clinical practice a similar promise can be made. Of course errors, particularly those which may recur in other situations, must be reported using the appropriate system in order to help the system learn. However this does not have to be on a naming and shaming basis but rather a collective effort to explain how an error happened, how it was dealt with and how it may be prevented in the future. In addition this is an opportunity to stress that you will not talk about any mistakes behind people's backs or use the reporting system as a weapon to punish people.<br />
<br />
<h4>
Psychological safety and mistakes</h4>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjvEKCGIUeiFIALiK20bLPwXsR4fRnzxHKPbRMJyqm_mNBBPT4ZU7qHl04tjqTkyfT4oWm_F478YpE8kXfHZwtBj-9oZnduZmzFhf8ksz2JKLsWIQkvucHnC2SscmevP_AetWaSTkJFw0o/s1600/safety.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="202" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjvEKCGIUeiFIALiK20bLPwXsR4fRnzxHKPbRMJyqm_mNBBPT4ZU7qHl04tjqTkyfT4oWm_F478YpE8kXfHZwtBj-9oZnduZmzFhf8ksz2JKLsWIQkvucHnC2SscmevP_AetWaSTkJFw0o/s320/safety.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Staff psychological safety will improve patient health</td></tr>
</tbody></table>
One
of the concerns that people may have is that the “psychologically safe”
unit/team/department will be more tolerant of error and therefore make more
mistakes.<span style="mso-spacerun: yes;"> </span>In 1996, Amy Edmondson looked
at eight hospital units and, with the help of a survey instrument and a blinded observer, rated their psychological
safety with respect to medication errors. She found that the
more psychologically safe the unit was, the greater the number of errors
reported. However, she also found that the more psychologically safe the unit, the fewer medication
errors the staff actually made. <u>Units which were not psychologically safe not
only reported fewer errors but made more.</u></div>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
</div>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
<span style="font-family: inherit;"><span lang="EN-US" style="text-indent: -18pt;"><br /></span></span>
<br />
<h4>
<span style="font-family: inherit;"><span lang="EN-US" style="text-indent: -18pt;">Final thoughts</span></span></h4>
<span style="font-family: inherit;"><span lang="EN-US" style="text-indent: -18pt;"><span style="font-family: inherit;">Words shape our thinking and we struggle to discuss a concept if we don't have a name for it. </span>It is time that the term "psychological safety" escapes the confines of the simulation centre and enters clinical practice. We all deserve psychological safety at work and you can help make this a reality by using some of the above tips.</span></span><br />
<span style="font-family: inherit;"><span lang="EN-US" style="text-indent: -18pt;"><br /></span></span>
<br />
<h4>
<span style="font-family: inherit;"><span lang="EN-US" style="text-indent: -18pt;">References</span></span></h4>
<span style="font-family: inherit;"><span lang="EN-US" style="text-indent: -18pt;">1)<span style="font-size: 7pt; line-height: normal;">
</span></span><span lang="EN-US" style="text-indent: -18pt;">EDMONDSON,
A. C. & LEI, Z. 2014. Psychological safety: The history, renaissance, and
future of an interpersonal construct. <i>Annual Review of Organizational
Psychology and Organizational Behavior,</i> 1, 23-43.</span></span></div>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
<span style="text-indent: -18pt;"><span style="font-family: inherit;"><br /></span></span></div>
<div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;">
<span style="font-family: inherit;"><span style="text-indent: -18pt;">2)<span style="font-size: 7pt; line-height: normal;">
</span></span><span lang="EN-US" style="text-indent: -18pt;">GALVAN, C., BACHA, E.
A., MOHR, J. & BARACH, P. 2005. A human factors approach to understanding
patient safety during pediatric cardiac surgery. <i>Progress in Pediatric
cardiology,</i> 20, 13-20.</span></span><br />
<span style="font-family: inherit;"><span lang="EN-US" style="text-indent: -18pt;"><br /></span></span>
<span style="font-family: inherit;"><span lang="EN-US" style="text-indent: -18pt;">3) EDMONDSON, A. C. 1996. Learning from mistakes is easier said than done: Group and organizational influences on the detection and correction of human error. The Journal of Applied Behavioral Science, 32, 5-28.</span></span></div>
<div class="MsoListParagraphCxSpLast" style="mso-list: l0 level1 lfo2; text-align: justify; text-indent: -18.0pt; text-justify: inter-ideograph;">
<o:p></o:p></div>
Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com0tag:blogger.com,1999:blog-3508305836023632036.post-36426518633579192712016-09-15T15:38:00.003+01:002016-09-15T15:43:57.043+01:00Book of the month: Bounce by Matthew Syed<div class="" style="clear: both; text-align: left;">
<span style="background-color: rgba(255 , 255 , 255 , 0); font-family: "helvetica neue light" , , "helvetica" , "arial" , sans-serif;"><b>About the author</b></span></div>
<div class="" style="clear: both; text-align: left;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgeqXox91ciQfw7ZNaEFWhJY5FMIR6ZfPOafkKRkogozu0M6-QCt6KPiva72UZZW-YaXBbF5brXHqR9SDo_dNXu7QCSkJYQSA7bdNRli8RN-_x8VTa5umALNsaG8voEXF3R4aaOynKJzdc/s1600/bounce.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgeqXox91ciQfw7ZNaEFWhJY5FMIR6ZfPOafkKRkogozu0M6-QCt6KPiva72UZZW-YaXBbF5brXHqR9SDo_dNXu7QCSkJYQSA7bdNRli8RN-_x8VTa5umALNsaG8voEXF3R4aaOynKJzdc/s200/bounce.jpg" width="133" /></a><span style="background-color: rgba(255, 255, 255, 0);">Matthew Syed (</span><a href="https://twitter.com/matthewsyed" style="background-color: rgba(255, 255, 255, 0);" target="_blank">@matthewsyed</a><span style="background-color: rgba(255, 255, 255, 0);">) is a journalist and was the English number one table tennis player for <a href="https://en.wikipedia.org/wiki/Matthew_Syed" target="_blank">almost ten years</a>. </span></div>
<h4>
<div style="text-align: justify;">
<div style="text-align: start;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><br /></span></div>
</div>
</h4>
<h4 style="text-align: start;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">Who should read this book?</span></h4>
<div style="text-align: start;">
<div style="text-align: justify;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">Anybody involved in education and training will find something useful in this book. Although there are a few problems, they are more than outweighed by the readability of this book and the transferability of the acquired knowledge into practice. Syed talks about the myth of innate talent, deliberate practice, expertise, motivation, the benefits of standardisation, the training of radiologists and <a href="http://scotsimcentre.blogspot.co.uk/2013/02/inattentional-blindness-or-whats-that.html" target="_blank">inattentional blindness</a>.</span></div>
</div>
<h4 style="text-align: justify;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><br /></span></h4>
<h4 style="text-align: justify;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">In summary</span></h4>
<div>
<div style="text-align: start;">
<div style="text-align: justify;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">The book is divided up into 3 Parts and 10 Chapters:</span></div>
<br />
<div style="text-align: justify;">
Part I: The Talent Myth. Here Syed effectively destroys the myth of innate talent. He tells us what you need is opportunity, deliberate practice with feedback and luck. </div>
</div>
</div>
<div>
<ol>
<li style="text-align: justify;"><span style="-webkit-text-size-adjust: auto;">The Hidden Logic of Success</span></li>
<li style="text-align: justify;"><span style="-webkit-text-size-adjust: auto;">Miraculous Children?</span></li>
<li style="text-align: justify;"><span style="-webkit-text-size-adjust: auto;">The Path to Excellence</span></li>
<li style="text-align: justify;"><span style="-webkit-text-size-adjust: auto;">Mysterious Sparks and Life-Changing Mindsets</span></li>
</ol>
<div>
<div style="text-align: justify;">
Part II: Paradoxes of the Mind. In this part Syed look at how our beliefs can help (or hinder) us.</div>
</div>
<ol start="5">
<li style="text-align: justify;"><span style="-webkit-text-size-adjust: auto;">The Placebo Effect</span></li>
<li style="text-align: justify;"><span style="-webkit-text-size-adjust: auto;">The Curse of Choking and How to Avoid It</span></li>
<li style="text-align: justify;"><span style="-webkit-text-size-adjust: auto;">Baseball Rituals, Pigeons, and Why Great Sportsmen Feel Miserable after Winning</span></li>
</ol>
<div>
<div style="text-align: justify;">
Part III: Deep Reflections. This part is less obviously related to the preceding parts (see "What's bad about this book?" below)</div>
</div>
<ol start="8">
<li style="text-align: justify;"><span style="-webkit-text-size-adjust: auto;">Optical Illusions and X-ray Vision</span></li>
<li style="text-align: justify;"><span style="-webkit-text-size-adjust: auto;">Drugs in Sport, Schwarzenegger Mice, and the Future of Mankind</span></li>
<li style="text-align: justify;"><span style="-webkit-text-size-adjust: auto;">Are Blacks Superior Runners?</span></li>
</ol>
</div>
<h4 style="text-align: justify;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">What's good about this book?</span></h4>
<div style="text-align: start;">
<div style="text-align: justify;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">This book is well-written and very easy to read. As someone who has "been there" Syed does a great job of debunking the talent myth (or the "myth of meritocracy" (p.7)) He references a few of the other writers in this field including Malcolm Gladwell (p.9) and Anders Ericsson (p.11)</span></div>
</div>
<div style="text-align: start;">
<br /></div>
<div>
<div style="text-align: justify;">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhXvIYfwpIzjkxi-Q5Yc9YP-rzSi6uZjeA5xgiZRLe9XQe_4tx1na6nO0Xh1InV1Acc61t10hQsdK9MrY6ScpQscsuWfJZzz888uW40F76tYOuIM0zChdOsl0p-SORwiIKV1EvpQQLeOUU/s1600/Screen+Shot+2016-09-15+at+12.14.43.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="88" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhXvIYfwpIzjkxi-Q5Yc9YP-rzSi6uZjeA5xgiZRLe9XQe_4tx1na6nO0Xh1InV1Acc61t10hQsdK9MrY6ScpQscsuWfJZzz888uW40F76tYOuIM0zChdOsl0p-SORwiIKV1EvpQQLeOUU/s320/Screen+Shot+2016-09-15+at+12.14.43.png" width="320" /></a></div>
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">Syed explains why the talent myth is bad, in part because it means we give up too quickly because "we're just not good at it". The talent myth also means that "talented" people are given jobs which they are not suited for, this may be a particular problem in government.</span></div>
</div>
<div>
<div style="text-align: justify;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><br /></span></div>
</div>
<div>
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEizp06CVOq2Vlack1oemZVONxNjD_UadjMNjLf0oAR0txL43DoreqH8uwcfH1FOqMWErQPR_drVQnyyrdk7snhqfj2P4CqlRGNpmTDVGcDE9PfRDaafspjx0sQYakojWiP2B_Pox8t9oZY/s1600/Screen+Shot+2016-09-15+at+12.27.07.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="121" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEizp06CVOq2Vlack1oemZVONxNjD_UadjMNjLf0oAR0txL43DoreqH8uwcfH1FOqMWErQPR_drVQnyyrdk7snhqfj2P4CqlRGNpmTDVGcDE9PfRDaafspjx0sQYakojWiP2B_Pox8t9oZY/s320/Screen+Shot+2016-09-15+at+12.27.07.png" width="320" /></a><span style="background-color: rgba(255, 255, 255, 0); text-align: justify;">This book is relevant to the acquisition of skills (technical and non-technical): Syed refers to Ericsson when he says tasks need to be "outside the current realm of reliable performance, but which could be mastered within hours of practice by gradually refining performance through repetitions" (p.76) In addition, mastery of skills leads to automaticity and a decrease in mental workload.</span><br />
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"></span><br />
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">
</span>
<br />
<div style="text-align: justify;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><span style="background-color: rgba(255, 255, 255, 0);">As mentioned in previous blog posts, failure is an important element of improvement and in order to improve we need to push ourselves (and our learners). Are your sessions set up in order to make the best possible use of the learners' time? </span></span><span style="background-color: rgba(255, 255, 255, 0);">Syed also explains that it is not just time (cf 10,000 hours) but the quality of the practice that is important.</span></div>
</div>
<div>
<div style="text-align: justify;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><br /></span></div>
</div>
<div>
<div style="text-align: justify;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">Syed extols the benefits of standardisation. He spent two months perfecting his stroke so that it would be identical "in every respect on each and every shot" (p.94). This meant that now he could introduce small changes and he would be able to tell if these were improvements or not as the rest of the stroke remained the same. There is a strong argument for similar standardisation or reduction in variation within healthcare. Currently it is extremely difficult to see whether a change is an improvement because of the variation in the system.</span></div>
</div>
<div>
<div style="text-align: justify;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><br /></span></div>
</div>
<div>
<div style="text-align: justify;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">"Feedback is the rocket that propels the acquisition of knowledge (p.95-96). Syed again refers to Ericsson when he discusses how the training of radiologists and GPs could be improved by giving them access to a library of material where the diagnosis is already known (e.g. mammograms for radiologists, heart sounds for GPs). Because the participants are given immediate feedback on their diagnosis they can learn very quickly from their mistakes. Could your skills or simulation centre offer something similar?</span></div>
</div>
<div>
<div style="text-align: justify;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><br /></span></div>
</div>
<div>
<div style="text-align: justify;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">Syed also deplores the lack of adoption of purposeful practice outwith the sports arena. He quotes one business expert: "There is very little mentoring or coaching... and objective feedback is virtually non-existent, often comprising little more than a half-hearted annual review" (p.103). How many of our workplaces can identify with this?</span><br />
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><br /></span>
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">Syed's final chapter "Are Blacks Superior Runners?" is a very well-written argument that it is economic and social circumstances that result in more black people being motivated to take up sport and excel in it. The false belief that black people have sporting talent, but are intellectually inferior, is part of a wider culture of discrimination, where for example people with 'black'-sounding names are less likely to be invited to a job interview.</span><br />
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><br /></span></div>
</div>
<h4 style="text-align: justify;">
<span style="background-color: rgba(255, 255, 255, 0);">What's bad about this book?</span></h4>
<h4 style="text-align: justify;">
<span style="font-weight: normal;">Syed commits the same mistake as Gladwell (which is nicely <a href="http://www.salon.com/2016/04/10/malcolm_gladwell_got_us_wrong_our_research_was_key_to_the_10000_hour_rule_but_heres_what_got_oversimplified/" target="_blank">refuted by Ericsson here</a>) that "(w)hat is required is ten thousand hours of <i>purposeful</i> practice" (p.85) or that it takes 10,000 hours to "achieve excellence" (p.15) </span></h4>
<div>
<div style="text-align: justify;">
Syed changes Ericsson's "deliberate practice" to "purposeful practice". Although he does explain his reasoning, this change does not improve our understanding of what the term stands for and is an unnecessary variation.</div>
</div>
<div>
<div style="text-align: justify;">
<br /></div>
</div>
<div>
<div style="text-align: justify;">
Syed states that "some jobs <i>demand</i> deep application... nurses are constantly challenged to operate at the upper limits off their powers: if they don't people die."(p.72) Unfortunately this is not the case. Most nurses (and most healthcare workers) do not work at the upper limits of their powers and patients do die. Healthcare currently neither rewards nor encourages excellence. Healthcare rewards, if not mediocrity, then not being noticed for the wrong reasons.<br />
<br />
Although applicable to sports, Syed's writing on the dispelling of doubt, does not translate well into healthcare. "Positive thinking" must not turn into the cognitive trap of "false positivism" and a degree of doubt is necessary for safe care.<br />
<br />
Part III: Deep reflections consists of 3 chapters which seem to have been added, slightly <i>ad hoc</i>, to the end of the book (perhaps it wasn't long enough?) Syed's argument in Chapter 9 that a policy of "regulated permissiveness" would be better than the current doping ban does not hold water. It is more likely that everybody (who can afford it) will then be on the permitted drugs and the cat-and-mouse game between the dopers and the doping agencies would continue with the illegal drugs. With respect to the Haemoglobin-boosting drug EPO, Syed states: "It is only when [the haematocrit] is elevated above 55 per cent that the risks begin to escalate..." (p.226). When it is more likely that there is no safe limit for the haematocrit. In the same vein Syed states: "Moderate steroid use improves strength and aids recovery without significant damaging side effects" This begs the question: "Why are we not all taking a moderate amount of steroids?"<br />
<br /></div>
</div>
<h4>
<div class="separator" style="clear: both; text-align: center;">
</div>
</h4>
<h4 style="text-align: justify;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">Final thoughts</span></h4>
<h4>
<div style="text-align: justify;">
<div style="text-align: start;">
<span style="font-weight: normal;">Syed argues that standards are spiralling upward in a number of fields because "people are practising longer, harder (due to professionalism), and smarter." He also talks about coasting (driving car) and unfortunately this is where many of us end up. Once the exams are finished we neither push ourselves nor are we pushed.</span><br />
<span style="font-weight: normal;"><span style="-webkit-text-size-adjust: auto;"><br /></span>
<span style="-webkit-text-size-adjust: auto;">If we "institutionalised the principles of purposeful practice" (p.84) as Syed encourages us to do, our training would be more effective, healthcare workers more qualified and patients safer.</span></span></div>
</div>
</h4>
<h4 style="-webkit-text-size-adjust: auto; font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif; font-size: 14px;">
<div style="text-align: justify;">
</div>
</h4>
Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com1tag:blogger.com,1999:blog-3508305836023632036.post-4058035043314929922016-09-08T16:14:00.004+01:002016-09-08T16:14:46.470+01:00Harnessing the Power of Mistakes (by Vicky Tallentire)<div class="MsoNormal" style="text-align: justify;">
<span lang="EN-AU" style="mso-ansi-language: EN-AU;">Mistakes
are an inevitable aspect of any system that involves decision-making; healthcare
is no exception.<span style="mso-spacerun: yes;"> </span>For better or for
worse, the mistakes that we make over the course of our careers define, to some
extent, who and what we become.<span style="mso-spacerun: yes;"> </span>In the
early days they often influence career decisions.<span style="mso-spacerun: yes;"> </span>Subsequently, they shape our approach to
work, subtly impacting on our communications with patients, our investigative
decisions and our willingness to discharge people home.<span style="mso-spacerun: yes;"> </span>For many nearing retirement, the timeline of
a career is a haze of professional satisfaction, punctuated by incidents of
avoidable harm recalled with the clarity of yesterday.<span style="mso-spacerun: yes;"> </span></span></div>
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<span lang="EN-AU" style="mso-ansi-language: EN-AU;"><br /></span></div>
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<span lang="EN-AU" style="mso-ansi-language: EN-AU;">Henry Marsh (1) describes the impact of
mistakes on his professional demeanour: “<i style="mso-bidi-font-style: normal;">At
the end of a successful day’s operating, when I was younger, I felt an intense
exhilaration. As I walked round the wards after an operating list… I felt like
a conquering general after a great battle. There have been too many disasters
and unexpected tragedies over the years, and I have made too many mistakes for
me to experience such feelings now…</i>”(p.33)<span style="mso-spacerun: yes;">
</span>Dealing with one’s own failures is, I think, the most challenging aspect
of a career in healthcare.<span style="mso-spacerun: yes;"> </span>How does one
balance the inevitable sorrow and guilt with the need to hold one’s head high
and continue to make high-stakes decisions? <o:p></o:p></span></div>
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<span lang="EN-AU" style="mso-ansi-language: EN-AU;">Medical
school lays the foundations for a career in medicine.<span style="mso-spacerun: yes;"> </span>The thirst for knowledge is
unparalleled.<span style="mso-spacerun: yes;"> </span>As Atul Gawande (2) says,
“<i style="mso-bidi-font-style: normal;">We paid our medical tuition to learn
about the inner process of the body, the intricate mechanisms of its
pathologies, and the vast trove of discoveries and technologies that have
accumulated to stop them. We didn’t imagine we needed to think about much else</i>.”(p.3)<span style="mso-spacerun: yes;"> </span>And yet we do.<span style="mso-spacerun: yes;"> </span>At medical school I was introduced to the
abstract concepts of error, unintended harm and, God forbid, mistakes.<span style="mso-spacerun: yes;"> </span>But I didn’t understand them concretely, like
I do now.<span style="mso-spacerun: yes;"> </span>That <i style="mso-bidi-font-style: normal;">I </i>will make mistakes, <i style="mso-bidi-font-style: normal;">I </i>will
cause harm, inflict distress and compound misery.<span style="mso-spacerun: yes;"> </span>That one day <i style="mso-bidi-font-style: normal;">I </i>would be crouched on the floor beside a patient, with the hateful
glare of a relative fixed on the back of my head, uttering “<i style="mso-bidi-font-style: normal;">I’m sorry</i>”.<o:p></o:p></span></div>
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<span lang="EN-AU" style="mso-ansi-language: EN-AU;">Don’t we,
as a profession, have a duty to better prepare our future doctors to deal with
their own failings?<span style="mso-spacerun: yes;"> </span>Shouldn’t we augment
the vast knowledge of pathophysiology with self-awareness, emotional resilience
and the language of professional but meaningful apology?<span style="mso-spacerun: yes;"> </span>The challenges are great, but so too are the
rewards.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span lang="EN-AU" style="mso-ansi-language: EN-AU;">Immersive simulation
is a tool that facilitates rehearsal of high-stakes decision-making in
emotionally charged situations. Mistakes are more than likely in such contexts.<span style="mso-spacerun: yes;"> </span>The debrief allows participants to reflect on
their actions, off-load emotionally and discuss the possible consequences of
alternative choices.<span style="mso-spacerun: yes;"> </span>That journey of
self-discovery and emotional development is, in my mind, what underpins the
power of immersive simulation.<span style="mso-spacerun: yes;"> </span>The
challenge now is how that journey can be continued, and supported, in the
workplace.<o:p></o:p></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-AU" style="mso-ansi-language: EN-AU;">References</span></b></div>
<div class="MsoNormal" style="text-align: justify;">
</div>
<ol>
<li><span style="text-indent: -18pt;">Henry Marsh. Do No Harm: Stories of
Life, Death and Brain Surgery. Published by Weidenfeld & Nicolson, 2014.</span></li>
<li><span style="text-indent: -18pt;">Atul Gawande. Being Mortal: Illness,
Medicine and What Matters in the End. Published by Profile Books Ltd, 2014</span></li>
</ol>
<div>
<b>About the author:</b><br />
<div style="text-align: justify;">
Vicky Tallentire is a consultant in acute medicine at the Western General Hospital in Edinburgh. She has an interest in the training of physicians, and has held a number of roles in the Royal College of Physicians in Edinburgh. Vicky has a particular interest in simulation based research and completed a doctorate at the University of Edinburgh in 2013 using simulation as a tool to explore decision-making and error. She is keen to develop the research profile of the centre and would like to hear from anyone, from any professional background and at any level, who is interested in undertaking research projects in the field of simulation.</div>
</div>
Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com0tag:blogger.com,1999:blog-3508305836023632036.post-13197767360689395952016-04-29T08:24:00.000+01:002016-04-29T08:30:56.466+01:00Book of the month: The Invisible Gorilla: And Other Ways Our Intuitions Deceive Us by Christopher Chabris and Daniel Simons<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg4D1h80RpJBf43FA4jyVfxtv4PqAJ2UQhb9eG4Yyd_4-bo6KJkczZJJWLC-D8Ep9ycqzNrmaB5AwKEEYPslvUqmtvrMm2m0ohQg1vfiWFLs_iHWZXoe4_K5dTHpDUqIMJNcOfOaHDwHi8/s1600/invisiblegorilla.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em; text-align: justify;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg4D1h80RpJBf43FA4jyVfxtv4PqAJ2UQhb9eG4Yyd_4-bo6KJkczZJJWLC-D8Ep9ycqzNrmaB5AwKEEYPslvUqmtvrMm2m0ohQg1vfiWFLs_iHWZXoe4_K5dTHpDUqIMJNcOfOaHDwHi8/s320/invisiblegorilla.jpg" width="212" /></a></div>
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<span style="background-color: rgba(255, 255, 255, 0);">About the authors</span><br />
<span style="font-weight: normal;">Christopher Chabris (</span><a href="https://twitter.com/cfchabris" style="font-weight: normal;" target="_blank">@cfchabris</a><span style="font-weight: normal;">) is an associate professor of psychology and co-director of the neuroscience programme, Union College, New York. Daniel Simons (</span><a href="https://twitter.com/profsimons" style="font-weight: normal;" target="_blank">@profsimons</a><span style="font-weight: normal;">) </span><span style="font-weight: normal;">is a professor in the department of psychology and the Beckman Institute for Advanced Science and Technology at the University of Illinois. Chabris and Simons ran one of the most famous experiments in psychology, the "invisible gorilla" (<a href="http://www.theinvisiblegorilla.com/videos.html" target="_blank">video</a>). A blogpost discussing the conclusions to be drawn from their experiment and related ones is available here: <a href="http://scotsimcentre.blogspot.co.uk/2013/02/inattentional-blindness-or-whats-that.html" target="_blank">Inattentional blindness or "What's that gorilla doing there?"</a>.</span><br />
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Who should read this book?</h4>
<div style="text-align: justify;">
Anybody with an interest in human performance limitations will find this book an interesting read. In addition, many of the concepts are useful to gain insight into how people perform within a simulated environment and in clinical practice.</div>
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">In summary</span></h4>
<div>
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">The book is divided up into an Introduction, six chapters and a Conclusion. The six chapters are:</span></div>
</div>
<div>
<ol>
<li style="text-align: justify;">"I Think I Would Have Seen That"</li>
<li style="text-align: justify;">The Coach Who Choked</li>
<li style="text-align: justify;">What Smart Chess Players and Stupid Criminals Have in Common</li>
<li style="text-align: justify;">Should You Be More Like a Weather Forecaster or a Hedge Fund Manager?</li>
<li style="text-align: justify;">Jumping to Conclusions</li>
<li style="text-align: justify;">Get Smart Quick!</li>
</ol>
</div>
<h4 style="text-align: start;">
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<span style="font-weight: normal; text-align: start;">Chabris and Simons explore and explain a number of misconceptions we have about our own abilities. Each chapter focuses on a specific "illusion": attention, memory, confidence, knowledge, cause, and potential. Chabris and Simons are interested in the fact that, not only do we suffer from these illusions, but we also are unaware of them and are surprised when they are pointed out.</span><br />
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<h4 style="text-align: justify;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">What's good about this book?</span></h4>
<div style="text-align: justify;">
This book is well-written and very easy to read. Each chapter focuses on one topic and is peppered with everyday examples to illustrate concepts. These include motorcycle collisions, film continuity errors, a sense of humour, and lifeguards in swimming pools.</div>
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<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgXbZwdCYSRtQwWXqlwQ465wa_qW1h9H4x6BhiOqnNypuRz_ck6mVPfaJ7DkivrhYqrCSjijHQFKpGsoTm2bqWv7hC7-osX7tEBmRN_JQ6uLSbdY-gxotnUQVWdkL6pf4gmtuDK5rbbpBE/s1600/watchoutforbikes.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="92" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgXbZwdCYSRtQwWXqlwQ465wa_qW1h9H4x6BhiOqnNypuRz_ck6mVPfaJ7DkivrhYqrCSjijHQFKpGsoTm2bqWv7hC7-osX7tEBmRN_JQ6uLSbdY-gxotnUQVWdkL6pf4gmtuDK5rbbpBE/s320/watchoutforbikes.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Not an effective way to change behaviour</td></tr>
</tbody></table>
In Chapter 1 the authors discuss why cars hit motorcycles (at times due to inattentional blindness) and they also explain why "Watch out for motorcycles" posters and adverts are not effective. They suggest that making motorcycles look more like cars, by having two widely separated headlights, would make them more visible to other car drivers. The same concept of "attention" also explains why the risk of collision with a bicycle or motorcycle decreases as the number of these forms of transport increase. The more often people see a bicycle on the road, the more likely they are to expect to see one and look for one.The authors also provide additional details about the various illusions. For example, eye-tracking experiments have shown that those who do not see the "invisible" gorilla spend as much time directly looking at it as those who do.</div>
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Chapter 2 looks at memory and uses persuasive experimental evidence to convince the reader that memory is fallible. In particular, contrary to popular belief, people do not have crystal clear memories of what they were doing during exceptional events such as 9/11 or Princess Diana's death. People think they do, because they think they should, and therefore are confident about these (unclear) memories.<br />
<br />
Chapter 3 explores confidence. The first example used is a doctor who looks up a diagnosis and treatment, which makes his patient feel very uneasy. Isn't a doctor supposed to know this stuff? We encounter similar situations in simulation, with the tension between appearing confident and being able to admit ignorance often results in a less than ideal outcome. The notion of moving from unconscious incompetence to unconscious competence is also covered here, by referring to an article ("<a href="http://psych.colorado.edu/~vanboven/teaching/p7536_heurbias/p7536_readings/kruger_dunning.pdf" target="_blank">Unskilled and Unaware of It</a>") which begins with a description of an inept bank robber.<br />
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<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjm-UJqRiOBqGm6222sCVPV2q82YJTLSyYmk-1Li7sRLuS_iMbJ7g6Z3i_01F1YooqNO2y5MpNGtzwvhDExziyb25_PjK3_bxhjH49iq387dzz17a6UZdDvegn7AJNZM0xzEy7KIijIG2w/s1600/bike.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjm-UJqRiOBqGm6222sCVPV2q82YJTLSyYmk-1Li7sRLuS_iMbJ7g6Z3i_01F1YooqNO2y5MpNGtzwvhDExziyb25_PjK3_bxhjH49iq387dzz17a6UZdDvegn7AJNZM0xzEy7KIijIG2w/s200/bike.jpg" width="200" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Would you ride this bike?</td></tr>
</tbody></table>
Chapter 4 explains why we often think we know more than we do. The authors make this point by asking the reader to draw a bicycle and then to compare this against the real thing. (Italian designer Gianluca Gimini has created some interesting <a href="http://www.bikeradar.com/news/article/these-7-crazy-bike-designs-are-completely-unrideable-and-we-love-them-46814/" target="_blank">3-D renderings</a> of people's concepts of what a bike looks like.) This illusion of knowledge, they argue, played a part in the 2008 banking crisis as bankers thought they understood both the banking system and the extremely complex collateral debt obligations (CDOs). </div>
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<br /></div>
<div style="text-align: justify;">
In Chapter 5 Chabris and Simons explore causation and correlation. While many people with arthritis think they can tell when the weather is about to change, researchers have found no correlation. It is likely that their pain levels fluctuate but if the weather changes they then ascribe their pain to the change in atmospheric pressure.<br />
<br />
In Chapter 6 the authors debunk the Mozart Effect, which led parents to play Mozart to babies in the belief that it would make them smarter. Similar claims by Lumosity, a company which alleged that playing its games would delay age-related cognitive impairment, resulted in a $2 million lawsuit.</div>
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">What's bad about this book?</span></h4>
<h4 style="text-align: justify;">
<span style="font-weight: normal;">There is very little to fault this book. Chabris and Simons call limitations in human performance "illusions" because, like M. C. Escher's prints, they persist even when you know what they are. The authors do a great job of explaining the illusions but do not spend enough time addressing the ways in which we might improve our ability not to succumb to them. </span></h4>
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">Final thoughts</span></h4>
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In terms of simulation, this book explains a number of behaviours that we witness in the simulated environment. For example, it is not unusual for participants to "lie" about something that happened. They may be adamant that they called for help, but the debriefer knows (and the video shows) that this was not the case. The participant is falsely remembering a call for help because they think that they would always call for help.<br />
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Again, in terms of the illusion of confidence, we find that those who are least able are often most confident because they lack the insight required to know how poor their performance is.<br />
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In terms of human factors, this book will provide a number of examples of human fallibility for workshops or other courses. It also reinforces the need for systems which help humans. As an example, changes in a patient's end-tidal CO2 (ETCO2) trace can suggest physiological impairment, but most machines do not make the clinician aware of these. A smarter monitor would alert the clinician to these changes instead of relying on his or her continued awareness. </div>
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Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com0tag:blogger.com,1999:blog-3508305836023632036.post-64901571766729666252016-03-30T22:06:00.001+01:002016-03-30T22:10:19.924+01:00Sharpening the saw: everyday debriefing practice<div style="text-align: justify;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgW2Exnd5g-8j6rB62Y0pXbIOhrHgR-dfvq9m0b26OuQ7JztEwu1QgPsukftChsW52KpldD6gZ7GW56iKJfLXpMvvUiQQF1dg7uwZTSeNxBE_6XhKIuzPCtNy_MHvkCTIZ-EyXtMnMu6Ak/s1600/saw.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgW2Exnd5g-8j6rB62Y0pXbIOhrHgR-dfvq9m0b26OuQ7JztEwu1QgPsukftChsW52KpldD6gZ7GW56iKJfLXpMvvUiQQF1dg7uwZTSeNxBE_6XhKIuzPCtNy_MHvkCTIZ-EyXtMnMu6Ak/s320/saw.jpg" width="320" /></a>Participants on our 2-day introductory faculty development course are given all the tools they need to plan, run and debrief a simulated experience aligned to learning objectives. However, on returning to their own workplaces, they often do not have the opportunity to run simulations regularly. This lack of practice means that their skills in debriefing do not improve as quickly as they would like. Also participants often mention that they don't have the time to carry out a 40 minute debrief. The good news is that they don't have to.</div>
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In Stephen Covey's book "<a href="https://www.stephencovey.com/7habits/7habits.php" target="_blank">The 7 Habits of Highly Effective People</a>", the seventh habit is "Sharpen the Saw". This habit, which includes social, emotional and physical well-being, also focuses on learning. This blogpost will explain how you can "sharpen the saw" <u>every day</u> with respect to debriefing in a few straightforward steps:</div>
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1) <u>Find a learner</u></div>
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Anybody will do (a trainee, a student, a colleague...)</div>
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2) <u>Rustle up some learning objectives</u></div>
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The learning objectives can come from your learner (e.g. "What do you want to focus us on today?" "What do you want to get out of today?" "What have you been struggling with?") Or they can come from you. </div>
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3) <u>Have an experience together</u></div>
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This can be pretty much anything. Inserting a nasogastric tube, carrying out a laparoscopic cholecystectomy, doing the drug round on a ward, going on a home visit, etc. The proviso is that you must have enough mental workspace available to observe the learner. This does not mean that you must be "hands off". However if you are too involved in the experience yourself, perhaps because it is complicated or time-critical, you are unlikely to be able to have a conversation with the learner about their performance.</div>
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4) <u>Practice your debriefing skills (as per the SCSCHF method)</u></div>
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a) Reactions</div>
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Ask him/her how that felt. What are their emotions about the experience.</div>
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b) Agenda</div>
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Ask him/her what they thought went well and what the challenges were.</div>
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c) Analysis</div>
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The assumption is that you don't have the time to spend 30 minutes in this phase of the debrief, so focus on just one thing. Use good questioning technique (taught on the faculty development course) to delve into the mental frames, heuristics, assumptions etc. which led to this being a challenge or a good performance.</div>
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d) Take Home Messages</div>
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What is your learner going to differently or the same next time based on your facilitated discussion.</div>
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5) <u>Get feedback</u></div>
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Practice does not make perfect, practice makes permanent. Deliberate practice with feedback propels you up the slope towards perfection. So get feedback from the learner. What was good about the way you helped them learn, what didn't work? If you can, now and again get a colleague, who has also been on the faculty development course, to sit in on the above and also give you feedback.</div>
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6) <u>Reflect on your performance</u></div>
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This does not have to take long or to be done then and there. At some stage reflect on your performance with the benefit of the feedback you have obtained. What are you going to do differently next time?</div>
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7) <u>Repeat</u></div>
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Do steps 1-6 again. Tell us how you get on....</div>
Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com0tag:blogger.com,1999:blog-3508305836023632036.post-76335077967924567512016-03-23T06:21:00.000+00:002016-03-23T06:25:12.901+00:00Simulation and Learner Safety<div style="text-align: justify;">
Primarily when we talk about safety in simulation we are referring to patient safety. Patient safety in two senses. The first is that one of the main reasons for carrying out simulation is to improve patient safety by looking for latent errors, improving teamwork, testing equipment, etc. The second is that "no patient is harmed" during simulation exercises.</div>
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In the brief before the simulation event, safety is also often mentioned in the establishment of a "safe learning environment (SLE)" and, in this context, it refers to Learner Safety. A recent clinical experience reinforced my appreciation of the SLE.</div>
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It was 10pm and I was resident on-call when my phone went off to tell me that a poly-trauma was on its way in. 2 adults and 3 children had life-threatening injuries after a collision on the motorway. Although I have been an anaesthetist for 13 years, a consultant for 5 of those, my clinical experience of polytrauma in adults is minimal and in children is essentially nil. I have looked after a man who had major injuries and 95% burns after an industrial explosion, another man who suffered severe injuries after he ran his car underneath a flatbed truck and the occasional stabbing and shooting victims. In children I have intubated a 2-week-old "shaken baby" and anaesthetised a large number of children on the trauma list for broken wrists, arms, ankles, etc. </div>
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When faced with infrequent events it is not unusual to carry out a memory scan to draw on previously obtained knowledge relevant to the situation at hand. I remembered the above patients and I also remembered a simulation course I had been on at the SCSCHF: <a href="http://scschf.org/courses/mepa-managing-emergencies-in-paediatric-anaesthesia-consultants/" target="_blank">Managing Emergencies in Paediatric Anaesthesia for Consultants</a> (MEPA-FC). My scenario involved a boy who had been run down by a car, he had a number of injuries including a closed intracranial bleed. My first thought when I remembered this scenario was "I did okay". Then I mentally went through the scenario again, thought about what had gone well and what, with input from the debrief, I should have done better. This then was the knowledge I had front-loaded and the emotional state I was in when the patients arrived in the ED.</div>
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When I talked through the above with David Rowney, the facilitator on the MEPA-FC course, he expressed surprise that my first thought was "I did okay" rather than remembering the Take Home Messages for my scenario. But there it is. It may be that I am very different from other people but I think it is not unusual to have an emotive reaction to a memory before a logical one.</div>
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This then made me think about the simulation participant who might not have had the SLE I had. The participant who, after their paediatric trauma scenario, had been dragged over the coals and made to feel incompetent. What would the emotional state of that doctor be as they walked down to the ED? And how would that affect their performance?</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEikxbMNdoemHzqrq60fvuXzSuM6jKhsgPBg2HrZWgdwv-qHT6orwVRSAswvvBvxvwmjaLX-hXYwDMCUfEIYDX-TFolZQlloPFBhu8EsntJRB2MHmcCjPrCRXFsSl6wBVKAO0baMeiGaF0s/s1600/Screen+Shot+2016-03-21+at+16.57.43.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="93" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEikxbMNdoemHzqrq60fvuXzSuM6jKhsgPBg2HrZWgdwv-qHT6orwVRSAswvvBvxvwmjaLX-hXYwDMCUfEIYDX-TFolZQlloPFBhu8EsntJRB2MHmcCjPrCRXFsSl6wBVKAO0baMeiGaF0s/s200/Screen+Shot+2016-03-21+at+16.57.43.png" width="200" /></a>This blogpost is not a plea to "take it easy" or "be gentle" with participants. Poor performance must be addressed, but it must be addressed in a constructive manner. Help the participant understand their performance gaps and how to bridge them, while at the same time remembering "I'm okay. You're okay." Very few of us come to work (or to the simulation centre) to perform poorly. In fact most people in a simulation are trying to perform at the peak of their ability. When they fall short it is important to help them figure out why that is, while re-assuring them that they are not "bad".</div>
Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com0tag:blogger.com,1999:blog-3508305836023632036.post-38496100438907330412016-03-09T10:59:00.000+00:002016-03-09T11:05:31.006+00:00Book of the month: Resilient Health Care (Hollnagel, Braithwaite and Wears (eds))<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgXBRrDJgrDfLJ_ynYJQ60CC0NV8hiGmSUTrVD1X2Enz4IuZt7HSgcyHXinMpWkX8G7eQOjf4m7aWv9WUUXTEstEPJoqAhCqE23T7rxSEUL8KqMWwJu9s0goNf3X4YQhb-qRv-_kT7DF6g/s1600/resilient.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em; text-align: justify;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgXBRrDJgrDfLJ_ynYJQ60CC0NV8hiGmSUTrVD1X2Enz4IuZt7HSgcyHXinMpWkX8G7eQOjf4m7aWv9WUUXTEstEPJoqAhCqE23T7rxSEUL8KqMWwJu9s0goNf3X4YQhb-qRv-_kT7DF6g/s320/resilient.jpg" width="212" /></a></div>
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<span style="background-color: rgba(255, 255, 255, 0);">About the editors</span></div>
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><div style="text-align: justify;">
<span style="font-weight: normal;"><a href="http://www.erikhollnagel.com/" target="_blank">Erik Hollnagel</a> has a PhD in Psychology and</span><span style="background-color: rgba(255, 255, 255, 0);"><span style="font-weight: normal;"> is a Professor at the University of Southern Denmark and Chief Consultant at the Centre for Quality Improvement, Region of Southern Denmark. He is the chief proponent of the Safety-II paradigm and helped to coin the term "resilience engineering".</span></span><br />
<span style="background-color: rgba(255, 255, 255, 0);"><a href="https://en.wikipedia.org/wiki/Jeffrey_Braithwaite" style="font-weight: normal;" target="_blank">Jeffrey Braithwaite</a>, <span style="font-weight: normal;">PhD, is the director and a professor of the Australian Institute of Health Innovation and the Centre for Health Care Resilience and Implementation Science, both based in the Faculty of Medicine and Health Sciences at Macquarie University, Australia. He is also an </span></span><span style="background-color: rgba(255, 255, 255, 0); font-weight: normal;">Adjunct Professor at the University of Southern Denmark.</span><br />
<span style="background-color: rgba(255, 255, 255, 0); font-weight: normal;">Robert Wears, MD, PhD, is an emergency physician and professor of emergency medicine at the University of Florida and visiting professor at the Clinical Safety Research Unit, Imperial College London.</span><br />
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About the contributors</h4>
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There are 27 other contributors, including well-known names such as Charles Vincent and <a href="https://twitter.com/TerryFairbanks" target="_blank">Terry Fairbanks</a>. The contributors are a world-wide selection, encompassing the US, Europe and Australasia. The majority are from a sociological/psychological research background rather than front-line clinical. </div>
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Who should read this book?</h4>
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This book will be of interest to those who are tasked with improving patient safety within their organisation, whether this is by collecting and analysing incident reports or "teaching" healthcare workers. It would be useful reading for board members, healthcare leaders and politicians involved in healthcare.</div>
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">In summary</span></h4>
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<span style="font-weight: normal;">The book is divided into 3 parts (18 chapters), as well as a preface and epilogue by the editors</span></div>
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<br /></div>
<ol type="I">
<li style="text-align: justify;"><span style="font-weight: normal;">Health care as a multiple stakeholder, multiple systems enterprise</span></li>
<ol>
<li style="text-align: justify;"><span style="font-weight: normal;">Making Health Care Resilient: From Safety-I to Safety-II</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">Resilience, the Second Story, and Progress on Patient Safety</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">Resilience and Safety in Health Care: Marriage or Divorce?</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">What Safety-II Might Learn from the Socio-Cultural Critique of Safety-I</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">Looking at Success versus Looking at Failure: Is Quality Safety? Is Safety Quality?</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">Health Care as a Complex Adaptive System</span></li>
</ol>
<li style="text-align: justify;"><span style="font-weight: normal;">The locus of resilience - individuals, groups, systems</span></li>
<ol start="7">
<li style="text-align: justify;"><span style="font-weight: normal;">Resilience in Intensive Care Units: The HUG Case</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">Investigating Expertise, Flexibility and Resilience in Socio-technical Environments: A Case Study in Robotic Surgery</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">Reconciling Regulation and Resilience in Health Care</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">Re-structuring and the Resilient Organisation: Implications for Heath Care</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">Relying on Resilience: Too Much of a Good Thing?</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">Mindful Organising and Resilient Health Care</span></li>
</ol>
<li style="text-align: justify;"><span style="font-weight: normal;">The nature and practice of resilient health care</span></li>
<ol start="13">
<li style="text-align: justify;"><span style="font-weight: normal;">Separating Resilience from Success</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">Adaptation versus Standardisation in Patient Safety</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">The Use of PROMs to Promote Patient Empowerment and Improve Resilience in Health Care Systems</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">Resilient Health Care</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">Safety-II Thinking in Action: 'Just in Time' Information to Support Everyday Activities</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">Mrs Jones Can't Breathe: Can a Resilience Framework Help?</span></li>
</ol>
</ol>
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">I haven't got the time to read 238 pages...</span></h4>
<div>
For the time-poor, the preface and epilogue are worth reading. Chapter 3 on the challenges resilience poses to safety, Chapter 5 on quality versus safety and Chapter 11, co-authored by Charles Vincent, on the downsides of resilience, are also worth reading.</div>
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<h4>
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">What's good about this book?</span></h4>
<span style="background-color: rgba(255, 255, 255, 0);">This book makes it clear that "resilience" can mean different things to different people. The authors identify resilience as part of the defining core of a system, something a system <i>does</i></span><span style="background-color: rgba(255, 255, 255, 0);"> rather than something that it <i>has </i>(p.73, p.146, p.230)</span><span style="background-color: rgba(255, 255, 255, 0);">. This is in contrast to some who call for more resilient healthcare workers, with the implication that if they were "tougher" then they would make fewer mistakes. Resilience is also not just about an ability to continue to function but an ability to </span><span style="background-color: rgba(255, 255, 255, 0);">minimise losses and maximise recovery (p.128).</span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgCtgHTFf2ud_nWur4xpFtG5K-yrejI-Eo91Q05ei-dKWwTsmDg-ZQIe5aXndZnivAR23mhICJ48wBLa-8cCs7SSNJhIPd0Kuj7zgWN1eigIsIYuUPy3bOpEPrp9foNb55MebnoiO-XnEQ/s1600/Screen+Shot+2016-02-20+at+17.49.54.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em; text-align: justify;"><img border="0" height="126" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgCtgHTFf2ud_nWur4xpFtG5K-yrejI-Eo91Q05ei-dKWwTsmDg-ZQIe5aXndZnivAR23mhICJ48wBLa-8cCs7SSNJhIPd0Kuj7zgWN1eigIsIYuUPy3bOpEPrp9foNb55MebnoiO-XnEQ/s320/Screen+Shot+2016-02-20+at+17.49.54.png" width="320" /></a><span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><span style="background-color: rgba(255, 255, 255, 0);">The authors also make it clear that resilience is not a self-evident positive attribute. More resilience in a system does not come without cost including, for example, a system which may resist "positive" change, such as some of the changes that the patient safety movement is trying to embed. Safety may focus on standardisation and supervision while resilience focuses on innovation, personalisation and autonomy (p.29). In Chapter 3, René Amalberti argues that "it is not a priority to increase resilience in health care. The ultimate priority is probably to maintain natural resilience for difficult situations, and abandon some for the standard" (p.35).</span></span></div>
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><span style="background-color: rgba(255, 255, 255, 0);"><br /></span></span></div>
<div style="text-align: justify;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><span style="background-color: rgba(255, 255, 255, 0);">The book helps to explain the lack of rapid advance in patient safety because of the "economic, social, organisational, professional, and political forces that surround healthcare" (p.21). Healthcare may be unique in the diversity and strength of these influences. In addition the authors argue that there is a gap between the front-line and those who manage "safety" (p.42), a finding echoed by </span><a href="http://scotsimcentre.blogspot.co.uk/2014/11/book-of-month-managing-maintenance.html" style="background-color: rgba(255, 255, 255, 0);" target="_blank">Reason and Hobbs in their book on maintenance error</a><span style="background-color: rgba(255, 255, 255, 0);">.</span></span></div>
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><span style="background-color: rgba(255, 255, 255, 0);"><br /></span></span></div>
<div style="text-align: justify;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><span style="background-color: rgba(255, 255, 255, 0);">The book makes a good critique of the "measure and manage" approach of Safety-I (p.41) which:</span></span></div>
<div style="text-align: justify;">
<ul>
<li>is retrospective</li>
<li>focuses on the 10%</li>
<li>misses learning to be found in safe practice</li>
<li>focuses on the clinical microsystem rather than the wider socio-cultural, organisational, political system </li>
</ul>
</div>
<div style="text-align: justify;">
Lastly, much work is currently focused on standardisation, however the authors argue that we should acknowledge the inevitability of performance variability, the need to monitor it and to control it (by dampening it when it's going in the wrong direction and amplifying it when it's going in the right direction). (p.13) The standardisation that does improve resilience is the type that decreases the requirements for effortful attention or the need to memorise (e.g. checklists, layout of workplaces).</div>
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">What's bad about this book?</span></h4>
<h4 style="text-align: justify;">
<span style="font-weight: normal;">Throughout this book, resilience is linked with the Safety-II concept (e.g. "Chapter 1: Making Health Care Resilient: From Safety-I to Safety-II"). The argument for Safety-II can be a nuanced one, therefore a good book on resilience would use simple language and provide specific examples. This book fails on the former and performs poorly on the latter. In particular, how Safety-II can be put into practice now is only vaguely referred to. Even the chapters which purport to show resilience in action do not make this very clear. Exceptions include Chapter 12 "Mindful Organising and Resilient Health Care" which suggests that people should be shown their inter-relations, i.e. how their actions affect those who interact with a patient upstream and downstream. </span></h4>
<h4 style="text-align: justify;">
<span style="font-weight: normal;"><br /></span></h4>
<h4 style="text-align: justify;">
<span style="font-weight: normal;">At times, the championing of Safety-II gives its proponents the appearance of a cult, e.g. "Enlightened thinkers in both industry and academia began to appreciate..." (p.xxiv) while one must imagine that unenlightened thinkers continued to live in their caves. There are also attacks on the PDCA/PDSA cycle (p.177) and the use of barriers (p. 131) as Safety-I thinking. In addition Safety-I, as a term and paradigm, has been created by Safety-II advocates, and in fact "pure" Safety-I probably does not exist. For example: "In contrast to Safety-I, Safety-II acknowledges that systems are incompletely understood...", however very few people working in healthcare, even within a Safety-I system, would argue that they fully understand the system.</span></h4>
<div>
<span style="font-weight: normal; text-align: justify;"><br /></span>
<span style="font-weight: normal; text-align: justify;">One of the examples in the book of proactive safety management is the stockpiling of H1N1 drugs and vaccines in 2009. This was later deplored by a number of sources as the mild epidemic <a href="http://www.nature.com/nbt/journal/v28/n3/full/nbt0310-182.html" target="_blank">killed fewer people than seasonal flu</a> and millions of pounds of stockpiles had to be destroyed. </span></div>
<div>
<span style="font-weight: normal; text-align: justify;"><br /></span></div>
<div>
<span style="font-weight: normal; text-align: justify;">Lastly one of the arguments the authors use against Safety-I thinking is that focusing on the small number of adverse events means we miss the opportunity to look at all the times things went well. However, with 10% of patients admitted to UK hospitals being subjected to iatrogenic harm (Vincent et al 2008), the number of times things go wrong is still a large chunk of the total work.</span><br />
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">Final thoughts</span></h4>
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<span style="text-align: justify;">This book makes a strong argument that we must stop looking purely at what has gone wrong in order to find out how to prevent mistakes. It also makes it clear that healthcare, as a complex adaptive system, will not be "fixed" by silver bullets, and that all solutions to problems create their own problems.</span></div>
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<div style="text-align: start;">
The concepts underpinning Safety-II, which include an urge to focus less on incidents and accidents and more on things that go well, are antithetical to much current thinking within healthcare. In addition patients and their families would not accept "I'm sorry you were harmed but we're focusing on things that go right" as an apology. This means that rather than pushing Safety-II, it may be more effective to advocate Safety-III. In Chapter 12 this is defined as: </div>
<blockquote class="tr_bq" style="text-align: start;">
"... enactive safety - embodies the reactive [Safety-I] and proactive [Safety-II] and therefore both bridges the past and future, and synthesises their lessons and prospects into current action." (p.155)</blockquote>
Hollnagel himself says "...the way ahead does not lie in a wholesale replacement of Safety-I by Safety-II, but rather in a combination of the two ways of thinking" (p.16). Safety-III may turn out to be a quixotic <a href="https://en.wikipedia.org/wiki/Theory_of_everything" target="_blank">Theory of Everything</a>. Or it may mature into an accepted, practical and applied paradigm, with "a degree of autonomy at the interface with the patient, yet predictability and effectiveness at the level of the organisation" (p.132). Its adherents still have much work to do.<br />
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<h4>
Further reading:</h4>
<br />
Vincent, C., et al. (2008) Is health care getting safer? <i>British Medical Journal</i>, 2008;337:a2426.</div>
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Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com0tag:blogger.com,1999:blog-3508305836023632036.post-8001072365350749512016-02-10T20:13:00.000+00:002016-02-10T20:13:14.333+00:00Book of the month: A life in error: from little slips to big disasters by James Reason<h4>
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgYizKOznmCWe6TxxI3-I7yqQo4Zi_RbCsLBEV5OS4HV9KBRpPzs0HRap1MCBUCZK2YkGQTYyb0g0AE3OretzAsV_I-k8j-HU-syOg4gTUjwpg_qKO3860ChoDM9Y819gqSNiy1Xe2rR7o/s1600/lifeinerror.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgYizKOznmCWe6TxxI3-I7yqQo4Zi_RbCsLBEV5OS4HV9KBRpPzs0HRap1MCBUCZK2YkGQTYyb0g0AE3OretzAsV_I-k8j-HU-syOg4gTUjwpg_qKO3860ChoDM9Y819gqSNiy1Xe2rR7o/s1600/lifeinerror.jpg" /></a><span style="text-align: justify;">About the author</span></h4>
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James Reason is one of the greats in human factors research. English Wikipedia does not have an entry for him (the <a href="https://fr.wikipedia.org/wiki/James_Reason" target="_blank">French site does</a>). Instead we have to content ourselves with a page on perhaps his major contribution to broadening the appeal and understanding of human factors, the <a href="https://en.wikipedia.org/wiki/Swiss_cheese_model" target="_blank">Swiss cheese model</a> of accident causation. Reason is Professor Emeritus of Psychology at the University of Manchester and has authored numerous papers and books on human factors, including: Human error, The Human Contribution and <a href="http://scotsimcentre.blogspot.co.uk/2014/11/book-of-month-managing-maintenance.html" target="_blank">Managing Maintenance Error (A Practical Guide)</a><br />
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<span lang="EN-US">Who should read this book?</span></h4>
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Anybody with an interest in human factors and patient safety (see below for why).<br />
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<h4 style="text-align: justify;">
<span lang="EN-US">In summary</span></h4>
<div class="MsoNormal" style="text-align: justify;">
The book consists of 14 chapters:<br />
<ol>
<li>A Bizarre Beginning</li>
<li>Plans, Actions and Consequences</li>
<li>Three Performance Levels</li>
<li>Absent-minded slips and lapses</li>
<li>Individual differences</li>
<li>A Courtroom Application of the SIML (Short Inventory of Mental Lapses)</li>
<li>The Freudian Slip Revisited</li>
<li>Planning Failures</li>
<li>Violations</li>
<li>Organizational accidents</li>
<li>Organizational Culture: Resisting Change </li>
<li>Medical Error</li>
<li>Disclosing Error</li>
<li>Reviewing the Journey</li>
</ol>
</div>
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<span lang="EN-US">What’s good about this book?</span></h4>
<div class="MsoNormal" style="text-align: justify;">
The book is very well written and easy to read. Reason takes us on an humorous, insightful, autobiographical journey from his first encounter with "human error" to his later theories. The book explains a number of concepts. For example, Reason argues that some familiar objects develop local control zones (p.3). In healthcare, an IV cannula may exhibit this property. If one finds oneself with a syringe in hand, distracted and near a cannula there is a strong possibility that one will inject the contents of the syringe into the cannula. When the syringe contains local anaesthetic or 1:1000 adrenaline this may result in adverse consequences.<br />
<br />
Reason talks about differences between novices and experts. The former show a lack of competence, while the latter are much more likely to commit absent-minded slips, i.e. misapplied competence (p.21). Reason argues that, in absent-mindedness, it is the suppressive function which goes absent. Pre-programmed, habitual actions are normally actively suppressed, but in "strong habit intrusions" they are carried out by the distracted person.<br />
<br />
Reason discusses the "Stress-vulnerability hypothesis", people under chronic stress are more likely to have cognitive failures such as absent-minded slips and lapses (p.33). However he argues that association is not causation, and it may be that people who are more likely to complain of chronic stress may also me more likely to be absent-minded, i.e. that the same poor cognitive resource management is responsible for both.<br />
<br />
In his discussion of planning/decision-making, Reason describes the planning process and the sources of bias which lead to failure, grouping them by planning stage (p.56):<br />
<ol>
<li>Working database (e.g. recency, successes better recalled than failures)</li>
<li>Mental operations (e.g. covariation, "halo", hindsight)</li>
<li>Knowledge schema (e.g. confirmation, resistance to change, "effort after meaning")</li>
</ol>
<div>
<br />
For those interested in groups and organisations, Reason discusses "satisficing", i.e. groups will tend to select the first satisfactory outcome rather than an optimal one. He also looks at the heuristics of group decision-making, such as avoidance of uncertainty and selective organisational learning (p.59). In terms of accidents, Reason contrasts "individual" (frequent, limited) and "organisational" (rare, devastating) accidents. He therefore agrees with <a href="http://humanisticsystems.com/2014/10/02/safety-is-our-primary-goal/" target="_blank">Steven Shorrock</a> that having a sign which says e.g. "135 days since our last accident" does not tell you how safe the system is. Why? Because they have different causal sets (p.79).</div>
<div>
<br /></div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj56crn4fsFki9ipGlDArj0W1OLtt7DOAcCpurLRkxyiiymDwZsKaBwtadBsrOzrtsy5bDuzC-Upskxvio_AsSfiZTkRcNmH8Gt9vdQG4lTMDKt17zQAj5HZG-Ran6nLhljovjE_sbkk1Y/s1600/quote-to-leave-off-action-well-damn-me-if-i-do-you-know-foley-i-have-only-one-eye-i-have-a-right-horatio-nelson-255534.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj56crn4fsFki9ipGlDArj0W1OLtt7DOAcCpurLRkxyiiymDwZsKaBwtadBsrOzrtsy5bDuzC-Upskxvio_AsSfiZTkRcNmH8Gt9vdQG4lTMDKt17zQAj5HZG-Ran6nLhljovjE_sbkk1Y/s320/quote-to-leave-off-action-well-damn-me-if-i-do-you-know-foley-i-have-only-one-eye-i-have-a-right-horatio-nelson-255534.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">"Turning a blind eye" (Nelson commits a violation, p.68)</td></tr>
</tbody></table>
<div>
In terms of violations, that is conscious decisions to ignore or circumvent a rule, Reason argues that it is better to focus on decreasing the benefits of violations rather than trying to increase the costs of doing so. This means that one should look at why the system is promoting violations rather than punishing individuals for committing them.</div>
<div>
<br /></div>
<div>
Reason also covers latent conditions, active failures and how they combine with local triggers into an accident trajectory (p.75).<br />
<br /></div>
</div>
<h4>
<div style="text-align: justify;">
</div>
<span lang="EN-US"><div style="text-align: justify;">
What’s bad about this book?</div>
</span></h4>
<div class="MsoNormal" style="text-align: justify;">
At 124 pages, this is a short book, however it is probably too short. A lack of explanation may leave some readers puzzled. For example, on p.30 Reason states: "The correlation between [two independent samples of the Short Inventory of Mental Lapses] over the 15 items was 0.879." It would probably have been better to leave out the numbers or to explain them. His coverage of the planning process and its biases is too short and superficial, he mentions "groupthink" (p.61) and provides 8 main symptoms but does not explain these in sufficient detail to allow one to use this knowledge in practice.<br />
<br /></div>
<h4 style="text-align: justify;">
<span lang="EN-US">Final thoughts</span></h4>
<div class="MsoNormal" style="text-align: justify;">
This book spans the whole gamut of human factors science and touches on a great number of subjects including all the above, as well as a typology of safety cultures, vulnerable system syndrome (blame, deny, pursue wrong goals), why and how organisations resist change, models of medical error (plague, legal, person, system) and more. And if you would like an easy-to-read, broad introduction to human factors and healthcare then this book is a must-read.</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com0tag:blogger.com,1999:blog-3508305836023632036.post-37009003997670816372016-01-28T09:48:00.002+00:002016-01-28T09:52:13.415+00:00On the use and abuse of "human factors"<h4>
Words shape our world</h4>
<div style="text-align: justify;">
The words we use, and how we use them, not only allow people to know what we are thinking but also shape the <i>way</i> we think. As a car mechanic, for example, knowing what all the components of an engine are called will make it easier for her to talk to a fellow mechanic and think about what the problem might be and how to fix it.</div>
<br />
<h4>
"Human factors"</h4>
<div>
<div style="text-align: justify;">
In the podcast "<a href="http://www.rvc.ac.uk/small-animal-referrals/news-events/clinical-podcasts/13-human-factors-non-technical-skills-and-professionalism" target="_blank">Human factors, non-technical skills and professionalism</a>", Liz Chan, a specialist in Veterinary Anaesthesia and Analgesia at the Royal Veterinary College, University of London tells us:</div>
<blockquote class="tr_bq" style="text-align: justify;">
"Human factors were defined by a guy called Martin Bromiley, who set up the Clinical Human Factors Group [CHFG]... He defines them in such an excellent way I always steal his definition because it is, basically to paraphrase: 'Everything that makes us different from predictable machines.'"</blockquote>
<div style="text-align: justify;">
Although it is possible that Martin Bromiley used that definition, it is extremely unlikely and, in trying to paraphrase, Liz Chan has changed the meaning of the term "human factors". This means that the podcast listeners are also likely not to use the term appropriately and when they read human factors literature they may wonder how this fits with their definition.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
On their <a href="http://chfg.org/what-is-human-factors" target="_blank">website</a>, under "What is human factors?" the CHFG uses the <a href="http://www.ergonomics.org.uk/what-is-ergonomics/" target="_blank">Chartered Institute of Ergonomics and Human Factors</a> (CIEHF) definition of:</div>
<blockquote class="tr_bq" style="text-align: justify;">
"Ergonomics (or Human Factors) is the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimise human well-being and overall system performance."</blockquote>
An easier definition is provided by Martin Bromiley in a <a href="http://www.health.org.uk/blog/human-factors-approach" target="_blank">Health Foundation blog</a>.<br />
<blockquote class="tr_bq">
"I often talk about human factors making it easy to do the right things with reliability of outcome..."</blockquote>
So human factors is a science whose aim is to make it easy for us to do the right thing, and difficult to do the wrong thing.<br />
<br />
<h4>
The abuse of "human factors"</h4>
</div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhHEB13Vegdq4cqqkG_9NNqFy4ESKwIh2updDZ9YZlDUVTxWS8Yodq524AKgY9Es7sT4dbGw4rTxTbaRQoHSyRY7qUJt90F3KeTolMyoqxubp1x4wcdY5bhBonhsuYG4aXzfZuwmR3liV0/s1600/Screen+Shot+2016-01-28+at+09.16.47.png" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="196" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhHEB13Vegdq4cqqkG_9NNqFy4ESKwIh2updDZ9YZlDUVTxWS8Yodq524AKgY9Es7sT4dbGw4rTxTbaRQoHSyRY7qUJt90F3KeTolMyoqxubp1x4wcdY5bhBonhsuYG4aXzfZuwmR3liV0/s320/Screen+Shot+2016-01-28+at+09.16.47.png" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><br /></td></tr>
</tbody></table>
<div>
<div style="text-align: justify;">
A lack of clarity around the use of the term "human factors" means that when it is used in the press, for example, it is almost always in a pejorative manner. This reinforces the (false) idea that if we could remove the humans from the system then things would be much safer.</div>
</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
In his book, <a href="https://www.ashgate.com/pdf/SamplePages/Human_Contribution_Ch1.pdf" target="_blank">The Human Contribution</a>, James Reason argues that the predominant view of humans in complex systems is as "hazards" when they are often "heroes".</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Still one of the predominant examples of the latter view is the "<a href="https://en.wikipedia.org/wiki/US_Airways_Flight_1549" target="_blank">miracle on the Hudson</a>", when Captain Chesley B. "Sully" Sullenberger landed an Airbus A320 on the Hudson river in New York after both engines had failed due to bird-strike. But we didn't see headlines like this:</div>
<div style="text-align: justify;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhLRvaKOvIXZJ7ASn8oGqX82zi_3EYFaqvmWGTGEj1FLLFwkMSTxtNkfkSTWHPmt-5z_TSK5C19PGVN5inP3_oO7u4XlxglogeImcx0lLBTGvLdWsHOM8QIfB9ZfZ3lKIncM9KxRWQF6VU/s1600/Plane_crash_into_Hudson_River_%2528crop%2529.jpg" imageanchor="1"><img border="0" height="340" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhLRvaKOvIXZJ7ASn8oGqX82zi_3EYFaqvmWGTGEj1FLLFwkMSTxtNkfkSTWHPmt-5z_TSK5C19PGVN5inP3_oO7u4XlxglogeImcx0lLBTGvLdWsHOM8QIfB9ZfZ3lKIncM9KxRWQF6VU/s640/Plane_crash_into_Hudson_River_%2528crop%2529.jpg" width="640" /></a></div>
<div>
<br /></div>
<div>
</div>
<div>
<br /></div>
<div>
We should use the term human factors to refer to the science of ergonomics and avoid using it to mean "human error" (<a href="http://scotsimcentre.blogspot.co.uk/2014/05/its-all-human-error.html" target="_blank">itself a poor choice of words</a>). This will help us and others to have more meaningful discussions and clearer thinking on the causes of, and remedies for, incidents and accidents.</div>
<div>
<br /></div>
Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com1tag:blogger.com,1999:blog-3508305836023632036.post-58262509787389016992015-11-23T15:09:00.002+00:002015-11-23T15:48:41.568+00:00Soaring with eagles or swimming with sharks? Aviation, banking and healthcare<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7b9ALBXUL-Nb9dfPXeP1D8zFUbVe6_9-KBYacThvw4oNe9yAECjMZCfI4WuaEr4tmo_-5U8_m1hZsK6Kc-QDsCV6-IsHB8SAMU4p5Ch_euxAw-srcOP8037tNfDsHMRfG3WbgmcdGJBQ/s1600/shark.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="179" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7b9ALBXUL-Nb9dfPXeP1D8zFUbVe6_9-KBYacThvw4oNe9yAECjMZCfI4WuaEr4tmo_-5U8_m1hZsK6Kc-QDsCV6-IsHB8SAMU4p5Ch_euxAw-srcOP8037tNfDsHMRfG3WbgmcdGJBQ/s320/shark.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">"So, I should sell my shares in solar?"</td></tr>
</tbody></table>
<div style="text-align: justify;">
When Steven Shorrock (<a href="https://twitter.com/StevenShorrock" target="_blank">@StevenShorrock</a>), Safety Development Project Leader at EUROCONTROL, spoke at ASPiH 2015, he mused aloud whether the conference organisers might have been better to invite a speaker from the banking sector than from air traffic control. He recommended reading "Swimming with sharks" for an insight into the former and these are my thoughts after reading it.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
The book, "Swimming with sharks", published in 2015, is based on interviews with about 200 people who worked or recently worked in banking in London. The author, Joris Luyendijk, discusses the financial crash of 2008, which almost brought the developed world to its knees, as well as other scandals such as Libor trading, laundering of drugs money, assisting tax evasion and the fall of Lehman Brothers. The real substance of the book lies in the personal accounts of the people working in banking and their thoughts about the sector. There are definite similarities between healthcare and banking but also some important differences... </div>
<div style="text-align: justify;">
<br /></div>
<h4>
Similarities</h4>
<div style="text-align: justify;">
<u>Safety</u></div>
<div style="text-align: justify;">
In banking, compliance officers are meant to keep an eye on the traders and ensure that trades did not expose the bank to too much risk. However, as Luyendijk states: "...it is very difficult to put a number on a loss you have averted by saying no..." A football analogy may be apt. The goalkeeper is remembered less for the many saves than for the single goal which lost her team the game. In healthcare a similar effect may be seen with those who work in "patient safety" including simulation-based training. Because safety is a <a href="http://www.scotsimcentre.blogspot.co.uk/2013/10/book-of-month-crisis-management-in.html" target="_blank">"dynamic, non-event"</a>, interventions aimed at improving safety may be seen by both front-line staff and hospital board members as costly and time-consuming with little return on investment. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<u>Culture and sub-cultures</u></div>
<div style="text-align: justify;">
Although there is much talk in the NHS of changing "the culture". Shorrock suggested that healthcare may be more similar to banking in this respect too, with a plethora of "sub-cultures" rather than one over-arching culture. "Swimming with sharks" details a few of these sub-cultures. The dog-eat-dog world of the front office traders compared to the investment bankers in asset management, who are encouraged to make slow, deliberate moves. Luyendijk says that banks like to portray themselves as organisations organised like an army or an airport, but in fact they are "clusters of islands in the fog, staffed by mercenaries" (p.145). It may be suggested that the culture(s) of hospitals can approximate those of aviation, although distinct in terms of values and behaviours the over-arching goal is the same. When hospitals fail, their cultures resemble those of banks, each sub-culture putting its own interests first resulting in a <a href="http://www.bbc.co.uk/news/uk-england-cambridgeshire-34317265" target="_blank">disconnect between frontline staff and the Board</a>.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
"Culture" is also high on the investigation list of a Holmes-like consultant who helps banks prevent and detect rogue trading (p.145). Luyendijk quotes him: "Is this a place where somebody can raise his hand and say I made a mistake?" In healthcare too the culture of a specific department or ward will give you an insight into how safe it is for patients. Dysfunctional teams are unlikely to be safe teams.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Lastly, one of the interviewees states: "It's not the people who are bad: it's the culture..." The same may be said of healthcare. Individuals are expected to adapt to, adopt and accept the given culture within a unit, department or ward. Luyendijk, in his recommendations at the end of the book, says: "One thing I believe does <i>not</i> help is to reduce the problems with global finance down to individual character flaws... if you blame all the scandals as well as the crash on individuals you imply that the system itself is fine, all we need to do is to smoke out the crooks..." This "bad apple" theory is well-addressed by <a href="http://scotsimcentre.blogspot.co.uk/2013/06/book-of-month-field-guide-to.html" target="_blank">Sidney Dekker</a> and others. In fact the system/culture encourages certain types of behaviour and without changing the fundamental causes we are unlikely to see long-lasting change.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<u>Hierarchies and silos</u></div>
<div style="text-align: justify;">
Luyendijk refers to Gillian Tett, a <i>Financial Times</i> journalist, who argues that "the number-one problem in investment and megabanks is that everyone works in 'silos'". A compliance officer Luyendijk interviewed says: "We need to get rid of the idea of "the bank". That term implies a unity of action and purpose, as if there's an all-encompassing view driving the bank. There is no such thing. What we have is a collection of individuals in positions of power. Each of them manages his or her own world." The same personalities can be found in healthcare, with the clinical lead or general manager who looks after "their world" without reference to the needs of the wider organisation.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<u>Complexity</u></div>
<div style="text-align: justify;">
Some financial products have become so complex that very few people, even inside the bank, actually understand what they represent or how risky they are. "Even the risk and compliance people who were supposed to be our internal checks and balances... We had to teach them how to monitor us" (p.132). One of the causes of the crash of 2008 was that the complex financial products on offer, collateralised debt obligations (CDOs), although AAA-rated by ratings agencies, were filled with mortgages which people were not going to be able to repay. A similar level of complexity operates in healthcare. A Board which is not pro-active in understanding the everyday workings of the hospital risks thinking the place is much safer than it actually is. In addition, decisions made by the board (with the best of intentions) may have significant, unexpected implications on the shop floor.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<u>Lack of funding in IT</u></div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhxXYq4HWb0FJJl2KcIMCXCWf3dUGPPVMwiAmaxkpmE1kw939tW-XGHxUpI6gqlvi1MrsgFbymNGHsvMzlUfGM0Smzi-Ayua6iykbcYL0tffI9BRx2VEo886OZKyHkW0OkkO_YzJIUhiZQ/s1600/lantus.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="77" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhxXYq4HWb0FJJl2KcIMCXCWf3dUGPPVMwiAmaxkpmE1kw939tW-XGHxUpI6gqlvi1MrsgFbymNGHsvMzlUfGM0Smzi-Ayua6iykbcYL0tffI9BRx2VEo886OZKyHkW0OkkO_YzJIUhiZQ/s320/lantus.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Handwriting: <a href="http://southfloridainjuryaccidentblog.com/2013/10/08/doctors-poor-handwriting-causes-many-serious-medication-errors-and-drug-mistakes-fatal-ades-from-doctors-scrawl/" target="_blank">Lantus 8 Units misread as 80 Units</a></td></tr>
</tbody></table>
<div style="text-align: justify;">
"Your readers would be shocked if they realised just how crap the IT organisation is in many banks..." (p.141). The same is true in healthcare. Whether it is "<a href="http://www.theguardian.com/society/2013/sep/18/nhs-records-system-10bn" target="_blank">the biggest IT failure ever seen</a>" costing £10 billion of UK taxpayers' money or the fact that most hospital drug charts are still hand-written, IT investment in healthcare is lacking. This means that, as in banking, many systems don't "speak" to each other, multiple passwords are required for multiple systems and patients' notes are still folders where pages may go missing. The potential for errors is phenomenal.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<u>Short-termism</u></div>
<div style="text-align: justify;">
In part because of the risk of instant dismissal (see below, under Differences) bankers often have a short-term outlook (p.154). In the NHS, acceptance of a post is often "for life", particularly at the patient-facing end. However there are perhaps similarities with NHS board members where turnover is much more rapid. This means that the long-term effects of some decisions are not made obvious to board members who have moved on.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<u>Speaking up</u></div>
<div style="text-align: justify;">
A number of interviewees spoke of the futility of speaking up when witnessing poor practice. "I'd lose my job never to find a new one anywhere in the City. Meanwhile nothing would have changed" (p.188) The same can be said of healthcare, the fate of <a href="https://en.wikipedia.org/wiki/Stephen_Bolsin" target="_blank">Stephen Bolsin</a>, who spoke up about the Bristol heart surgery deaths, is <a href="http://www.telegraph.co.uk/news/health/news/11398148/The-NHS-whistle-blowers-who-spoke-out-for-patients.html" target="_blank">not unique</a>.</div>
<div style="text-align: justify;">
<u><br /></u></div>
<h4>
Differences</h4>
<div style="text-align: justify;">
<u>Focus</u></div>
<div style="text-align: justify;">
The focus of bankers and banks is to make money. Bankers want to make money for themselves and, in a meritocratic system, are rewarded for how much money they make for the bank. Public healthcare, as is generally found in the NHS (although the the English NHS seems to be on the road to privatisation) instead seems to be more focused on not losing money rather than trying to make a profit. This means that the majority of healthcare workers do not have a vested interest in increasing throughput or reducing costs.</div>
<div style="text-align: justify;">
</div>
<div style="text-align: justify;">
<u>Dismissal</u></div>
<div style="text-align: justify;">
In banking, dismissals are unexpected and immediate. To prevent the newly unemployed trader from damaging the bank, all network access is revoked and they are escorted from the building. In healthcare it is much more difficult to dismiss employees, even when their behaviour seems obviously unacceptable. Although at first glance it may seem preferable to be able to instantly dismiss "bad apples" or under performers, the effect this has on banking is not negligible. Bank employees may have much less loyalty to their bank and therefore may care little what effect their risk-taking has on "their" bank (e.g. <a href="https://en.wikipedia.org/wiki/Barings_Bank" target="_blank">Nick Leeson and Barings Bank</a>)</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<u>Professionalism</u></div>
<div style="text-align: right;">
</div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiP1w8e_QduQn5AMNyHPJhnJnDfOm2EO0Av71dwq0bONipPOi15CecPIVWbvBfOvFGWW0Ui7muwycZxpmCapccXGJhLnJGdqMNS7cV2u7b13Jeq8xW29sn-NqC-ar-ksDHuysIv9MQ1CBc/s1600/mori.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="230" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiP1w8e_QduQn5AMNyHPJhnJnDfOm2EO0Av71dwq0bONipPOi15CecPIVWbvBfOvFGWW0Ui7muwycZxpmCapccXGJhLnJGdqMNS7cV2u7b13Jeq8xW29sn-NqC-ar-ksDHuysIv9MQ1CBc/s320/mori.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">The "professional" doctor vs the "professional" banker</td></tr>
</tbody></table>
<div style="text-align: justify;">
In the City, the biggest compliment is 'professional'. "It means you do not let emotions get in the way of the work, let alone moral beliefs" (p.107). A recurring theme in <i>Swimming with Sharks</i> is that bankers are not immoral, but rather amoral. As long as an action is legal it is irrelevant whether it is "right" or "wrong". In healthcare the word "professional" may still mean <a href="http://www.medicalprotection.org/uk/advice-booklets/professionalism-an-mps-guide/chapter-1-medical-professionalism-what-do-we-mean" target="_blank">a number of different things</a> to different people, but what it most certainly does not mean is "amoral".</div>
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<br /></div>
<div style="text-align: justify;">
<br /></div>
<h4>
Final thoughts</h4>
<div style="text-align: justify;">
Was Steven Shorrock right? Is healthcare more like banking than aviation? In effect it can be like both. At its best, healthcare resembles aviation with its focus on safety and a desire to ensure that the passenger/patient gets to his destination/home in one piece. At its worst, healthcare resembles banking, with a climate of fear (p. 95), amorality, back-stabbing and a focus on money and targets (cf. <a href="http://www.health.org.uk/about-francis-inquiry" target="_blank">Mid-Staffs</a>). It is up to all of us to decide what kind of ward, department and hospital we want to work in. In particular it is the job of hospital leadership to foster a safety culture and sell the <i>idea </i>of "the hospital" or "the healthcare centre" that staff can be loyal to and work together for. Hospital leaders must also speak truth to power by making it clear that the current cost-cutting across the NHS <u>cannot</u> be making the organisation safer. It is the job of politicians to provide the funding required and to protect the nascent safety culture against accusations of "<a href="http://www.express.co.uk/news/uk/621164/harmful-mistakes-Scotland-NHS-doubled-SNP" target="_blank">blunders</a>" as more adverse events are reported.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
As for banking, Luyendijk makes a convincing argument that nothing substantial has changed. The basic weaknesses which almost brought the developed world to a standstill in 2008 remain in place. Unfortunately the political willpower to make the required root and branch reform is lacking.</div>
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<br /></div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<br /></div>
<h4>
Acknowledgments: </h4>
"Swimming with sharks" does not make a single reference to healthcare or human factors. I am unlikely to have read it without Steven Shorrock's recommendation for which I am grateful.<br />
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<br /></div>
Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com1tag:blogger.com,1999:blog-3508305836023632036.post-32934918338104415912015-10-28T07:27:00.001+00:002015-10-28T07:27:19.700+00:00Book of the month: Human Factors and Behavioural Safety by Jeremy Stranks<h4>
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjvWhQfItlAyUQ0WdndZCnKznpgkzdWyVlGVijVbKH1BHrecXXLhK-D4v0GI2121sABXGM9KTnpeQ-n3wSQQ49m28ND2Hh2gEgFUqDUcyE6atKun050z6fQp8FZFsu6pZWgvxMJ8nbtItY/s1600/stranks.jpeg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjvWhQfItlAyUQ0WdndZCnKznpgkzdWyVlGVijVbKH1BHrecXXLhK-D4v0GI2121sABXGM9KTnpeQ-n3wSQQ49m28ND2Hh2gEgFUqDUcyE6atKun050z6fQp8FZFsu6pZWgvxMJ8nbtItY/s200/stranks.jpeg" width="132" /></a><span style="text-align: justify;">About the author</span></h4>
<div class="MsoNormal" style="text-align: justify;">
According to the book's blurb Jeremy Stranks "has 40 years' experience in occupational health and safety enforcement, management, consultancy and training." Stranks is the author of a number of books on health and safety, including "The Handbook of Health and Safety Practice" and "Stress at Work: Management and Prevention".</div>
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<h4 style="text-align: justify;">
<span lang="EN-US">Who should read this book?</span></h4>
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</div>
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The book will be of use to simulation centre directors and managers. Specific chapters may be interesting for others involved in simulation-based medical education.<br />
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<h4 style="text-align: justify;">
<span lang="EN-US">In summary</span></h4>
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The book consists of 19 chapters:<br />
<br />
<ol>
<li>Human behaviour and safety</li>
<li>Human sensory and perceptual processes</li>
<li>Organizations and groups</li>
<li>People factors</li>
<li>Perception of risk and human error</li>
<li>Organizational control and human reliability</li>
<li>Improving human reliability</li>
<li>Ergonomic principles</li>
<li>Ergonomics and human reliability</li>
<li>Principles of communication</li>
<li>Verbal and nonverbal communication</li>
<li>Written communication</li>
<li>Interpersonal skills</li>
<li>Systematic training</li>
<li>Presentation skills</li>
<li>Health and safety culture</li>
<li>Change and change management</li>
<li>Stress and stress management</li>
<li>The behavioural safety approach</li>
</ol>
</div>
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<br /></div>
<h4 style="text-align: justify;">
<span lang="EN-US">What’s good about this book?</span></h4>
<div class="MsoNormal" style="text-align: justify;">
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgovDGWB_KHV7asqHzTXpkmAgpfbnP5YCallU25BHECP9p5WyxSNh1SyzpsR6GCiQYSs7cQzAdVjWbBTH0f7Rn7U1Qz7MRHoq2HwX0Mrlu1585sPwvez87FAWMhPm__UUG91ybAVMPY1Yo/s1600/Screen+Shot+2015-10-20+at+21.09.31.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="161" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgovDGWB_KHV7asqHzTXpkmAgpfbnP5YCallU25BHECP9p5WyxSNh1SyzpsR6GCiQYSs7cQzAdVjWbBTH0f7Rn7U1Qz7MRHoq2HwX0Mrlu1585sPwvez87FAWMhPm__UUG91ybAVMPY1Yo/s400/Screen+Shot+2015-10-20+at+21.09.31.png" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">How many criteria does your sim centre/programme meet?</td></tr>
</tbody></table>
Stranks provides good descriptions of theories which may be unfamiliar to healthcare professionals. <a href="https://en.wikipedia.org/wiki/Two-factor_theory" target="_blank">Herzberg's two-factor theory of job (dis)satisfaction</a> (p.10) argues that the basic needs of employees, "hygiene factors", need to be met before job satisfaction can be improved through "motivators". For example, an employee is unlikely to be satisfied with having a challenging job if her supervision and working environment are poor.<br />
<br />
McGregor's <a href="https://en.wikipedia.org/wiki/Theory_X_and_Theory_Y" target="_blank">Theory X and Theory Y</a> (p.73) are also explored. Theory X says that people don't like to work and will not work unless coerced. Theory Y says that people will work if they are provided with the right environment in which their inherent motivation will emerge. Stranks also provides an overview of other concepts more familiar to simulation and human factors personnel such as Rasmussen's model of behaviour (p.123), error classification (p.127), the Swiss cheese model (p.130) and others.<br />
<br />
Stranks provides a good overview of the elements and implementation of a behavioural safety programme including significant workforce participation, a data-driven decision process and peer-to-peer monitoring (p.28-29). He also drives home the need for "clear and evident commitment from the most senior management downwards, which promotes a climate for safety..." (p. 93) A need which is evident (and largely unmet) in healthcare.<br />
<br />
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgS-qDPS8ocTflQTztk4SMLM37krFpC8Avw2mNPpqyXcIEXD9hv1Sv1gY0WAHPKPL_O7D621e5kz4jUZBpNhqOtjji_QsZP6k7tVA9Sce5cE1tFWfHMZ8x8oxHJGED7wHgjKtxXlbBmqeA/s1600/Screen+Shot+2015-10-26+at+22.32.10.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgS-qDPS8ocTflQTztk4SMLM37krFpC8Avw2mNPpqyXcIEXD9hv1Sv1gY0WAHPKPL_O7D621e5kz4jUZBpNhqOtjji_QsZP6k7tVA9Sce5cE1tFWfHMZ8x8oxHJGED7wHgjKtxXlbBmqeA/s320/Screen+Shot+2015-10-26+at+22.32.10.png" width="313" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Hale and Hale (1970)</td></tr>
</tbody></table>
Stranks describes accident prevention strategies and classifies them according to whether they are pro-active or reactive. Proactive strategies include "safe place" and "safe person" (p. 43). This concept may also be applied to healthcare. The safe place aims to ensure that the the premises, the equipment, the processes, etc. are safe. The safe person refers to behaviour, vulnerable people (e.g. those lacking in experience) and personal hygiene (e.g. hand washing).<br />
<br />
A number of chapters are of interest to simulation faculty and those involved in research, including the chapter on risk perception. Simulation faculty may find that Hale and Hale's model of human performance in relation to accident causation (p. 112) could provide a structure to a debrief analysis.<br />
<br /></div>
<h4>
<div style="text-align: justify;">
</div>
<span lang="EN-US"><div style="text-align: justify;">
What’s bad about this book?</div>
</span></h4>
<div class="MsoNormal" style="text-align: justify;">
<br />
The lack of referral to references makes the book more difficult to read than it need be. For example, on page 15 Stranks states: "Most people can only take in and retain 3.1 'bits' of information at any one time." This is probably a reference to Miller's seminal "<a href="http://psychclassics.yorku.ca/Miller/" target="_blank">The magical number seven, plus or minus two: Some limits on our capacity for processing information</a>". However Miller's paper refers to 3.1 bits only for some types of data, such as "hue" and "pitch and loudness". A similar problem occurs on p.26 when Stranks provides a (long-winded) definition of human factors. It is unclear if it is his own or from elsewhere.<br />
<br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEirSH529_yeoC5H_XlWJokhhi23YtqAvVHDN3R3ub9pV4jLHFAUd-q24GZBBYfmSZgeCkJlPG9QmC7TMX04GIspepv3BxBmNK82d-BX_rhoJUjAiBbcsxKwHeWW0jgYHkMm5rBxyyiF4ik/s1600/Photo+on+27-10-2015+at+16.52.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="124" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEirSH529_yeoC5H_XlWJokhhi23YtqAvVHDN3R3ub9pV4jLHFAUd-q24GZBBYfmSZgeCkJlPG9QmC7TMX04GIspepv3BxBmNK82d-BX_rhoJUjAiBbcsxKwHeWW0jgYHkMm5rBxyyiF4ik/s320/Photo+on+27-10-2015+at+16.52.jpg" width="320" /></a>Stranks talks about some concepts (e.g. task fixation, alarm fatigue) without referring to their titles. This makes it more difficult for the novice to link Stranks' writing with prior knowledge. Some of the concepts are poorly explained (such as fault tree analysis (p.40) and the total working system (p.213)) and occasionally the Figures are unclear (e.g. Figure 7.1, p.169). Some concepts are superficially covered but then not linked to anything else (e.g. Learning styles, p.174) and the chapters could generally have better introductions to show the logical flow of argument/idea. </div>
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<div class="MsoNormal" style="text-align: justify;">
Stranks uses human factors in the plural: "What are human factors?" (p.90) and singular: "Human factors has an important role..." (p.100). He uses the term "ergonomics" to mean the scientific discipline. While this may be purely semantic, it would probably be clearer to define the terms and then stick to those definitions.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgeulwrMKaEY5W8SOji-nVcQIJjslLJyJ0w0egA4T_h7pYY9c1Y6WTgiG3KxgNpLzLVF-WNXcqcOe52V6ZH9Pb6qjRyg8WCTwd35KzZRG_y65PkwzKHWvtqJmvsUClrqNRvQXr1mZ2TjRI/s1600/Screen+Shot+2015-10-27+at+17.16.18.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgeulwrMKaEY5W8SOji-nVcQIJjslLJyJ0w0egA4T_h7pYY9c1Y6WTgiG3KxgNpLzLVF-WNXcqcOe52V6ZH9Pb6qjRyg8WCTwd35KzZRG_y65PkwzKHWvtqJmvsUClrqNRvQXr1mZ2TjRI/s320/Screen+Shot+2015-10-27+at+17.16.18.png" width="216" /></a></div>
Stranks states that "The ultimate objective (for engineers) is to design equipment which requires the least physical and mental effort on the part of the operator" (p.208). One could argue that this is not true. The equipment should probably require just enough mental effort to keep the operator "in the loop" and engaged.<br />
<br />
Stranks argues that "The use of posters... repeating a specific message are important features of the safety communication process" (p.275). This is argued against by a number of human factors experts including Terry Fairbanks (see urinal pic).<br />
<br />
Lastly, the entire chapter on Presentation skills (chapter 15) should be skipped. If this is a problem then there are much better books out there such as "<a href="http://www.amazon.co.uk/dp/1447261135" target="_blank">Talk Like Ted</a>".<br />
<br />
<br /></div>
<h4 style="text-align: justify;">
<span lang="EN-US">Final thoughts</span></h4>
<div class="MsoNormal" style="text-align: justify;">
The entire contents of Stranks' book will not be of interest (or use) to the majority of people working in simulation-based medical education. However it may be of use to managers and directors and to people involved in clinical human factors. In addition, some chapters may be of interest to a wider audience and therefore a glance at the chapter headings may be worthwhile. Reading it with a "clinical" mindset, one can appreciate that the progression in safety management systems, the changes in culture required, and the elements and implementation of a behavioural safety programme are, with minor modifications, relevant to the healthcare environment.</div>
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<br />Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com0tag:blogger.com,1999:blog-3508305836023632036.post-58287835210403399852015-09-11T19:50:00.004+01:002015-09-11T20:51:02.112+01:00Breakfast at Auchrannie’s (Or: How bad systems can make good people
perform poorly) (by M Moneypenny)<div style="text-align: justify;">
Recently the family and I were lucky enough to be able to spend a few days at <a href="http://www.auchrannie.co.uk/" target="_blank">Auchrannie Spa and Resort</a> on the isle of Arran. I would recommend both Arran and the resort to anyone. It has won a slew of awards and, according to trip advisor, is the #2 hotel in Brodick. However, goings-on during breakfast compelled me to write a blogpost…</div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUlai5EUISFNPdQh6RTls41NlE7_hKOt_Yr1qcXZlKtBXNjFmstXetN4LinwaLsW3-cWQaKuqgn6p0LU3wLDuG5klCRvasDwmEWmHcuY2a9n1wwiax_40g9y15XJFRuA6yXLgkoxnISn8/s1600/IMG_1631.JPG" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUlai5EUISFNPdQh6RTls41NlE7_hKOt_Yr1qcXZlKtBXNjFmstXetN4LinwaLsW3-cWQaKuqgn6p0LU3wLDuG5klCRvasDwmEWmHcuY2a9n1wwiax_40g9y15XJFRuA6yXLgkoxnISn8/s200/IMG_1631.JPG" width="150"></a></td></tr>
<tr><td class="tr-caption" style="font-size: 13px; text-align: center;">A small selection of the awards</td></tr>
</tbody></table>
<br>
<h4>
The problem with vegans</h4>
<div style="text-align: justify;">
We are vegan which I had informed the hotel of weeks before, during the booking process. I received a lovely email in response which stated: “I have emailed the restaurant manager with regards to your request for vegan sausages.” On arrival at the breakfast buffet we were greeted by a very pleasant maître d’ who made sure we hadn’t just wandered in off the street, found us a table, and told me to talk to the waitering staff about the dietary requirement.
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<br></div>
<div style="text-align: justify;">
So we availed ourselves of the continental breakfast and then had chat with Sean who was looking after the hot food part of the buffet. Sean told me that they did have vegetarian sausages but that he thought they weren’t vegan. He said that he seemed to remember asking the chefs a while ago and that they had told him this, but that he would enquire.</div>
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<div style="text-align: justify;">
Sean then went through to the kitchen and had a chat with one of the chefs. After a little while he came back and told us that the sausages were in fact vegan. Great, we said, we’ll have three breakfasts please. Sean said: “Two?” And we said: “No, three, one for each of the adults and one to share between the kids.” It would take a wee while to make he informed us, as they would cook everything fresh.</div>
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<br></div>
<div style="text-align: justify;">
We sat back down and waited. And waited. And waited a little bit more. Then a friendly waiter called Will caught my eye and asked if we were okay. I told him we were waiting for our vegan breakfasts. Will said he would see what was happening. Unfortunately for him the swinging door into the corridor next to the kitchen has a clear glass window in it. This allowed me to see what happened next. Will walked through the door, looked into the kitchen, waited a little bit without speaking to anybody then turned around and came back to tell us that they were almost ready.</div>
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<br></div>
<div style="text-align: justify;">
Great. So we waited. And waited. And waited a little bit more. I took the kids over to the play area while my other half went to find Sean. Sean was very apologetic. He went into the kitchen to find out what was happening. He came back and informed us that the breakfasts hadn’t even been started yet. He had only talked to and asked (he said) one of the chefs to make the breakfasts and because he hadn’t written the order down they hadn’t done anything. Sean apologised profusely and said he would be back with our breakfasts. About 5 minutes later there he was with 2 plates which we gave to my better half (it was her birthday after all) and the kids. Sean wandered off. He didn’t come back. A few minutes later we managed to call him over and ask him about my breakfast and he said he thought we’d only wanted two and we said, no, three. Sean then came back a few minutes later with a single sausage on a plate…</div>
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<div style="text-align: justify;">
The following day things went much smoother, there was no maître d’ but Sean welcomed us, sat us down and brought us three breakfasts.</div>
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<h4>
Good people in a bad system</h4>
Other than being a somewhat boring story from my holiday (at least I’m not making you sit through holiday photos) what is the point of this blogpost? One major learning point for me is that even very caring people, who want to do the right thing, can be let down by the system. What improvements could be made?<br>
<br>
<ul>
<li>There were more than enough waiting staff to allocate them specific tables. This would mean that “our” waiter/waitress would know we had been waiting longer than we should have been. The current system was chaotic with tables cleared ad hoc, sometimes one waiter would get the cleaning spray out, leave it on the table to do something else then another waiter would clean the table.</li>
<li>If you take on a “problem” (and I’m using that term to describe us) then you own it until you have passed it on to someone else. We were Sean’s problem and he should’ve kept an eye on us.</li>
<li>Empower your staff. I have no idea why Will didn’t actually speak to anybody in the kitchen, but he did recognise that something was amiss and he could have flagged up with the chefs that a table was awaiting a vegan breakfast.</li>
</ul>
</div>
<div style="text-align: justify;">
<br></div>
The final give home message is that the staff at Auchrannie are some of the most pleasant and courteous I have ever met. However, they were let down by the lack of coordination at breakfast. The same can be true of healthcare, excellent staff working in a faulty system can still result in disappointed patients. (Names have been changed to protect the innocent) </div>
Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com0tag:blogger.com,1999:blog-3508305836023632036.post-9123048445418427352015-08-21T17:15:00.000+01:002015-08-21T17:26:58.163+01:00"They did too well"<div style="text-align: justify;">
When observing a new faculty member it is not unusual to see a look of relief on his/her face when the participants in a scenario (finally) make a mistake. The faculty member may believe that if no mistakes are made then the facilitator will have nothing to talk about in the debrief. Below are a few tips on how to deal with the participants who "did too well".<br />
<h4>
</h4>
<h4>
</h4>
<h4>
Don't create a special crisis</h4>
<div>
Some may be tempted to throw a curveball into the scenario. "They're doing great, okay... Your patient has now arrested and he's also aspirated." Try and avoid this. Your scenario should be running to your learning objectives. Creating a special crisis in order to have something to talk about in the debrief, means they're going to be talking about the crisis and not your learning objectives.</div>
<div>
<br /></div>
<h4>
It's not you, it's them</h4>
<div style="text-align: justify;">
The introductory paragraph contains an obvious mistake: "the facilitator will have nothing to talk about in the debrief". The debrief is not an opportunity for the facilitator to talk. The debrief allows the facilitator to <u>facilitate the discussion</u> the group is having. This means that the faculty member should concentrate on how to make sure the learning objectives get discussed, not on whether the participants did or didn't do well.</div>
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<br /></div>
<h4>
Good scenarios are not designed to create mistakes</h4>
<div>
Good scenarios are designed to explore performance based on the learning objectives of your course, some will do well, others less well. All performance can be discussed. The words of Peter Dieckmann and Charlotte Ringsted are worth remembering:</div>
<blockquote class="tr_bq">
"Learners' errors should not be seen as a personal victory in scenario design and implementation." <a href="http://scotsimcentre.blogspot.co.uk/2015/06/book-of-month-essential-simulation-in.html" target="_blank">(p.55 - Essential Simulation in Clinical Education (Forrest, McKimm and Edgar (eds)))</a></blockquote>
<h4>
</h4>
<h4>
<br /></h4>
<h4>
Be enthusiastic and explore</h4>
<div>
Although "advocacy and inquiry debriefing" may have its faults (<a href="http://scotsimcentre.blogspot.co.uk/2013/09/its-all-about-me-me-me-problem-with.html" target="_blank">see blogpost here</a>), its appeal to the facilitator to display genuine curiosity is a valid point. When the participants "did too well", why did that happen? What was their communication, leadership, teamwork, etc. like? How can we ensure that the next group of participants will do just as well?</div>
<h4>
</h4>
<h4>
<br /></h4>
<h4>
Final thoughts</h4>
<div>
The desire to see participants make mistakes is a phase in the evolution of the facilitator. Most move beyond it, happy in the knowledge that good performance is a fertile ground for discussion as much as poor performance is.</div>
<div>
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<div>
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</div>
Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com1tag:blogger.com,1999:blog-3508305836023632036.post-5149964338804050062015-07-26T18:21:00.000+01:002015-07-26T18:27:28.141+01:00When the equipment fails...<div style="text-align: justify;">
On 18th July 2015 Martin Bromiley tweeted:</div>
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The implication is that one should not pretend that something hasn't failed in a sim session. There are a few points for reflection here.</div>
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1) There are considerable differences between aviation and healthcare sim</h4>
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Airline pilots have much more exposure to simulation than the average healthcare worker, this means that equipment failure in aviation sim can be addressed by rescheduling the session. This is not normally the case in healthcare where a given participant may only be able to take part in a sim session every three years.</div>
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Aviation sims are much better funded than healthcare sims. In healthcare the use of out-of-date drugs and second-hand equipment is the norm. Equipment failure is therefore more likely in healthcare.</div>
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Healthcare sims also tend to involve the use of a plethora of equipment from different manufacturers and "cobbled-together" pieces of kit such as a simulated blood gas machine or a simulated X-ray machine. These are more likely to fail than bespoke flight simulators.</div>
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The bottom line? Aviation sims are less likely to fail and when they do, the ability to reschedule a sim session means that equipment failures can be "explored" to see how the participants cope with an unexpected problem.</div>
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2) There are different types of equipment failures</h4>
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One of the most common types of failure in (mannequin-based) simulation is the mannequin itself. Loss of power or communications with the controlling device can mean the mannequin "dies". Other equipment failures may mean that, for example, one cannot feel a pulse on one arm, or that the pupils don't dilate, or that the simulated blood gas machine stops working. The faculty response to each of these equipment failures will be different and this brings us on to point 3.</div>
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3) Response to equipment failure depends on the type of failure, faculty experience, the scenario and your learners</h4>
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If we take sudden mannequin failure as an example, and three different scenarios:</div>
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<li style="text-align: justify;">Patient in septic shock, hypoxic, hypotensive and moribund</li>
<li style="text-align: justify;">Patient with life-threatening asthma, silent chest and tiring</li>
<li style="text-align: justify;">Patient about to undergo elective surgery for laparoscopic cholecystectomy, chatting to anaesthetist</li>
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In the first two it would seem reasonable to continue the scenario, with a pulseless, lifeless patient while you try to re-establish connection to the mannequin (or plug him back in). In the third scenario, it would be best to interrupt the scenario, acknowledge a technical issue and fix it.</div>
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Of course, this still doesn't cover the "pretend it hasn't failed" situation. Imagine a home-made "X-ray machine" which displays an X-ray at the touch of a button. However, when the confederate radiographer goes to display the X-ray nothing happens. One option would be to get the participants to decide what they would do in such a situation in real life, e.g. get another X-ray machine, continue on clinical judgment, auscultate chest, ultrasound, etc.. Another option would be to "pretend it hasn't failed" with the confederate providing them with a hard-copy of the X-ray. This latter option may be particularly apt if the rest of the scenario depends on the ability of the participants to correctly interpret the X-ray.</div>
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Final thoughts</h4>
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This post should not come across as a <i>carte blanche </i>to make up for poor equipment maintenance or scenario planning. The "pretend it hasn't failed" response should be rare and limited to minor failures which will not throw the participants out of the simulated reality you have created for them (e.g. "I wasn't sure when he stopped breathing that he had really stopped or that you wanted us to pretend that he hadn't.") "Pretend it hasn't failed" is not the correct wording even when that is what you want the participants to do; well-trained faculty and confederates will be able to sculpt the scenario so that the equipment failure is quickly forgotten. "Pretend it hasn't failed" is also not the correct response when you are carrying out <i>in situ</i> systems-testing; the participants should deal with this as they would in real life. Lastly, if it's a course and the scenario learning objectives can still be achieved when the equipment has failed then, by all means, the participants should be allowed to develop their own solution to the problem. As faculty experience (and expertise) increases, one will become better at predicting the likely consequences of a failure and the best response.</div>
Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com1tag:blogger.com,1999:blog-3508305836023632036.post-74531233219645685242015-07-01T18:37:00.000+01:002015-07-01T18:37:12.610+01:00Two is a crowd<div style="text-align: justify;">
A team may, very loosely, be defined as two or more people working towards a common goal. The benefits of working in a team are manifold: shared physical and mental workload, balancing of strengths and weaknesses, error trapping, etc. More accurately, the preceding sentence should be modified to say "The benefits of working in a <i style="font-weight: bold;">good</i> team are manifold." We have all had experience of dysfunctional teams which were much less than the sum of their parts, and would probably have functioned better if the individuals had worked independently. As <a href="http://scotsimcentre.blogspot.co.uk/2014/11/book-of-month-managing-maintenance.html" target="_blank">Reason and Hobbs</a> state: "<span style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;">Team management errors are one of the most serious threats to safety... problems include":</span></div>
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<li style="text-align: justify;">team leaders being over-preoccupied with minor technical problems</li>
<li style="text-align: justify;">failure to delegate tasks and responsibilities</li>
<li style="text-align: justify;">failure to set priorities</li>
<li style="text-align: justify;">inadequate monitoring and supervision</li>
<li style="text-align: justify;">failures in communication</li>
<li style="text-align: justify;">failure to detect and/or challenge non-compliance with SOPs</li>
<li style="text-align: justify;">excessively authoritarian leadership styles</li>
<li style="text-align: justify;">junior members of the crew or team being unwilling to correct the errors of their seniors</li>
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Although much depends on effective team members, the above list suggests that good leadership is paramount. Ironically, the education system from primary school on to postgraduate education praises and rewards individual excellence. This means that the A+ students who have become excellent personal achievers are then expected to work in, and lead, teams with very little prior preparation for this role. Although courses, such as Advanced Life Support (ALS), expect candidates to show leadership skills, the team members are often faculty members and have to be spoon-fed instructions. Ostensibly this allows candidates to be assessed on their skills, without variable support from the team, but it creates unrealistic scenarios.</div>
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It is perhaps not surprising for the director of a simulation centre to suggest that simulation is part of the solution to team training. However, this is one of the greatest benefits of inter-professional simulation, whether <i>in situ</i> or in the simulation centre. Repeated practice with a focused debrief allows, some might say <b>forces</b>, teams to become more effective. There is still too much expectation within healthcare that competent individuals, when placed in the same room, will work well together. Unfortunately this is not the case. And practicing on an <i>ad hoc</i> basis with real patients is not only unethical but also ineffective; the lack of time for a debrief and the lack of uninvolved observers makes learning from real patients difficult. So, could your team could be practicing working together in a simulation centre (or <i>in situ</i>)? And if your team isn't doing this then how do you justify poor performance in real cases?</div>
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Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com0tag:blogger.com,1999:blog-3508305836023632036.post-88887591202068834582015-06-10T12:15:00.002+01:002015-06-10T12:16:18.987+01:00Book of the month: Essential Simulation in Clinical Education (Forrest, McKimm and Edgar (eds))<h4 style="text-align: start;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg1MaooAVRkRx1pVg_KbxL6v_Vsi8c3Iv8EgBjyq2N-m-H6fvrg97F5yANLE80ohRyenX7jNCZwaTFLdWMGaO-Yjxy3QB1HlJRI1X-kWmY4x7oPOiiiz2wuEgeU06rQ7OQmNAKWYcFB3dY/s1600/essentials.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg1MaooAVRkRx1pVg_KbxL6v_Vsi8c3Iv8EgBjyq2N-m-H6fvrg97F5yANLE80ohRyenX7jNCZwaTFLdWMGaO-Yjxy3QB1HlJRI1X-kWmY4x7oPOiiiz2wuEgeU06rQ7OQmNAKWYcFB3dY/s200/essentials.jpg" width="140" /></a><u style="font-weight: normal;">Disclaimer:</u><span style="font-weight: normal;"> The reviewer (M Moneypenny) co-authored a small section of a chapter in this book. He is also a friend of a number of the contributors (but has tried to write an objective piece!)</span><br />
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About the editors<br />
<span style="font-weight: normal;">Kirsty Forrest is Professor and Director of Medical Education at the Australian School of Advanced Medicine, Macquarie University, Sydney, Australia. Judy McKimm is Professor of Medical Education and Director of Strategic Educational Development at Swansea University, Swansea, UK. Simon Edgar is Director of Medical Education, NHS Lothian, Edinburgh, UK and Education Coordinator, SCSCHF, Larbert, UK. The three editors combine a significant amount of expertise in medical education, simulation and clinical practice.</span></div>
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About the contributors</h4>
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<span style="font-weight: normal;">There are 32 contributors (not including the editors), one from Ireland, one from New Zealand, 2 from Canada, 3 from the USA, 4 from Denmark and 21 from the UK. Although perhaps "UK-centric", the geographical spread results in a more diverse authorship than, for example, "<a href="http://www.scotsimcentre.blogspot.co.uk/2014/05/book-of-month-practical-health-care.html" target="_blank">Practical Health Care Simulations</a>". </span></div>
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Who should read this book?</h4>
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<span style="font-weight: normal;">The back cover states: "A superb companion for those involved in multi-disciplinary healthcare teaching, or interested in health care education practices…" In reality the book should probably be on the reading list for anyone who is starting out in simulation-based (medical) education. More experienced educators may find specific chapters, aligned with their own interests, of relevance.</span></div>
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">In summary</span></h4>
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The book is divided into 14 chapters:</div>
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<li style="text-align: justify;"><span style="font-weight: normal;">Essential simulation in clinical education</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">Medical simulation: the journey so far</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">The evidence: what works, why and how?</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">Pedagogy in simulation-based training healthcare</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">Assessment</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">The roles of faculty and simulated patients in simulation</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">Surgical technical skills</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">The non-technical skills</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">Teamwork</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">Designing effective simulation activities</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">Distributed simulation</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">Providing effective simulation activities</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">Simulation in practice</span></li>
<li style="text-align: justify;"><span style="font-weight: normal;">The future for simulation</span></li>
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">What's good about this book?</span></h4>
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<span style="font-weight: normal;">Every chapter starts with an overview and concludes with a short summary and an even shorter "key points" which is useful both as a reminder and as a reference for the reader in order to decide if the entire chapter is worth reading.</span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj4uh_kD8uON9a-vqEBZY8ROsRxeB_iX55TbdAZs0stpYxe9WsqJDdT7A5QqdPqqSb9KwRqyDADG0cTHhSrDzJwhFOoQ1egHU91B6wl-eTo5aX3q2DMaVgtXN356IoR9Kq9ujvUsACKkyQ/s1600/Screen+Shot+2015-06-09+at+17.12.54.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="108" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj4uh_kD8uON9a-vqEBZY8ROsRxeB_iX55TbdAZs0stpYxe9WsqJDdT7A5QqdPqqSb9KwRqyDADG0cTHhSrDzJwhFOoQ1egHU91B6wl-eTo5aX3q2DMaVgtXN356IoR9Kq9ujvUsACKkyQ/s320/Screen+Shot+2015-06-09+at+17.12.54.png" width="320" /></a></div>
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<span style="font-weight: normal;">The editors make it clear in Chapter 1 that simulation is not a panacea. This view has been echoed elsewhere by Andrew Buttery (@andibuttri) on Twitter and by Trisha Greenhalgh (@trishgreenhalgh) in the <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4220218/" target="_blank">British Journal of General Practice</a>. Simulation is not magic and not all simulation is "good" simulation. "High fidelity" is also placed into context by Tom Gale and Martin Roberts who state: "…the blind use of the highest fidelity available is a principle which should be avoided" (p.63).</span><br />
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<span style="font-weight: normal;">Chapter 3 "The evidence: what works, why and how?" by Doris Østergaard and Jacob Rosenberg is essential reading for all who are involved in designing simulation-based interventions and those undertaking research. They consider the features which make simulation effective, including feedback, deliberate practice and curriculum integration and they also look at some of the challenges faced by researchers in simulation.</span></div>
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">What's bad about this book?</span></h4>
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<span style="font-weight: normal;">The order of the chapters could be reconsidered. The chapters on designing and providing effective simulation activities would logically appear nearer the beginning of the book, and the chapter on assessment nearer the end. In addition, there is a chapter on "Teamwork" but not one on "Leadership" (although one might argue that good leadership is part of good teamwork). Lastly, an entire chapter on distributed simulation (DS), although interesting, is probably not required in a book covering "essential" simulation. A section on DS could have been included in the "Simulation in practice" chapter.</span><br />
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<span style="font-weight: normal;">Although overall a very good chapter, Chapter 5 "Assessment" by Thomas Gale and Martin Roberts refers to "assessment tools with appropriate reliability/validity…" (p.61). However the tools themselves are not inherently reliable or valid, the scores produced by the use of the tools may be, and then initially only within the context in which the tool was created.</span></div>
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This book covers the important topic areas well, including assessment, the roles of faculty and how to create effective simulations. This book therefore deserves a space on every simulation centre's bookshelf, as it provides a good overview of practical simulation in a digestible format.</div>
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Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com0tag:blogger.com,1999:blog-3508305836023632036.post-58086414402668390612015-05-27T20:51:00.002+01:002015-05-27T21:19:04.637+01:00Affordances and constraints<div style="text-align: justify;">
In human factors, one of the areas of interest is human-object interaction. Some objects are extremely easy to interact with, often because they have been designed from the beginning with the human user in mind. Examples might include the iPhone (other smartphones are available), and Dyson vacuum cleaners (other vacuum cleaners are available). Other objects can be more difficult to work out. Anybody who has had to fold up a child's buggy or change the time on an oven clock knows what I'm talking about.</div>
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In human-object interaction, an <b>affordance</b> describes the actions that a human can readily perceive are possible (Figure 1). Well-designed objects make it readily apparent how they should be used. For example, looking at two LEGO® bricks it is pretty clear that they are made to stack on top of one another.</div>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: justify;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhccvwjZvqkd3ibRsgnzBWKVQbdCfhDQi1OOcU-uZczngHZ5kDLW6E1EvS7IeKHh2-GESzQ3adDgdGnn2sktx-JC9drYoSTzb8Ledd-Vw_E4DkR1bHjz0p4GzveeKaCweQkjRMA0Dba0AA/s1600/IMG_0781.JPG" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhccvwjZvqkd3ibRsgnzBWKVQbdCfhDQi1OOcU-uZczngHZ5kDLW6E1EvS7IeKHh2-GESzQ3adDgdGnn2sktx-JC9drYoSTzb8Ledd-Vw_E4DkR1bHjz0p4GzveeKaCweQkjRMA0Dba0AA/s200/IMG_0781.JPG" width="200" /></a></td></tr>
<tr><td class="tr-caption" style="font-size: 13px; text-align: center;"><span style="text-align: start;"><span style="font-size: x-small;">Figure 1: The handle on a coffee mug<br />suggests that it can be used to hold the mug. </span></span></td></tr>
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A <b>constraint</b> is a design feature which stops an undesirable action (Fig. 2). The constraint may be physical or, for more complex objects, software-driven. Using LEGO® bricks again as an example, they tend to fit together in only very limited ways.</div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiWHnz5qR8K8eh36vbHfttc4o9SL5FmjHHNcx5vPhdBHKIvjYyCRk7U1QP1HQ5NNizkVHY0vqAsU5cMeQ2q5Fo1CAPIXL3udAHwxJBNVRVKbzHl2OGPuODkdNxpXLVUMWJRcWIQJ4kGa2Q/s1600/57151-a-remote-for-grandparents_w.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiWHnz5qR8K8eh36vbHfttc4o9SL5FmjHHNcx5vPhdBHKIvjYyCRk7U1QP1HQ5NNizkVHY0vqAsU5cMeQ2q5Fo1CAPIXL3udAHwxJBNVRVKbzHl2OGPuODkdNxpXLVUMWJRcWIQJ4kGa2Q/s320/57151-a-remote-for-grandparents_w.jpg" width="248" /></a></td></tr>
<tr><td class="tr-caption" style="font-size: 13px; text-align: center;">Figure 2: Some devices require post-manufacture<br />
constraints to be added.</td></tr>
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In healthcare, many devices are much more complicated than LEGO®. However good design, using affordances and constraints, plays a strong part in minimising errors.</div>
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The TCI pump</h4>
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The TCI pump is used to provide a target-controlled infusion of an anaesthetic (propofol) or a potent painkiller (remifentanil). The pump has a number of useful constraints to minimise errors. For example if you inadvertently press the power off button, the pump will display "LOCKED" (Fig 3) and forces the user to carry out a sequence of steps to ensure that this was the intended action. </div>
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<tr><td><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEglyDC7psmrrkiQq1ZcX2bklMq2l0u9PCfcwdgc3PVMng4BeijmXM5G4VLGcknoqEGfEhczS-M3XgU0nnxF49vgQSv6O5yMsSLFwL5FKVqwVbXeAj7_CKtiRLmbThywBcX0tgdM_Xmb-Sg/s1600/IMG_0763.JPG" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto; text-align: justify;"><img border="0" height="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEglyDC7psmrrkiQq1ZcX2bklMq2l0u9PCfcwdgc3PVMng4BeijmXM5G4VLGcknoqEGfEhczS-M3XgU0nnxF49vgQSv6O5yMsSLFwL5FKVqwVbXeAj7_CKtiRLmbThywBcX0tgdM_Xmb-Sg/s200/IMG_0763.JPG" width="200" /></a></td></tr>
<tr><td class="tr-caption" style="font-size: 13px;">Figure 3: OFF button "slip" error prevented</td></tr>
</tbody></table>
<div style="margin-left: 1em; margin-right: 1em; text-align: justify;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEggkDyhuqZgUMTDll21v8A2RQFV_ar5kc69lMdsZYfP0Au4R625qrORUOjx9RUgYk_X0b1Se0zp4Zr4YO0W42dYkhhAaVD_lQQJ5rM-ESON3nez1Xvfocehhb9KP9CuAvsTQAyje1fUj1I/s1600/IMG_0764.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"></a></div>
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<div class="separator" style="clear: both; text-align: center;">
</div>
<div class="separator" style="clear: both; text-align: justify;">
<span style="text-align: justify;">This sequence includes two additional safety steps. An "OK" button press (Figure 4) needs to be followed by a separate "CONFIRM" button press (Figure 5), preventing an inadvertent double press. </span></div>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEggkDyhuqZgUMTDll21v8A2RQFV_ar5kc69lMdsZYfP0Au4R625qrORUOjx9RUgYk_X0b1Se0zp4Zr4YO0W42dYkhhAaVD_lQQJ5rM-ESON3nez1Xvfocehhb9KP9CuAvsTQAyje1fUj1I/s1600/IMG_0764.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEggkDyhuqZgUMTDll21v8A2RQFV_ar5kc69lMdsZYfP0Au4R625qrORUOjx9RUgYk_X0b1Se0zp4Zr4YO0W42dYkhhAaVD_lQQJ5rM-ESON3nez1Xvfocehhb9KP9CuAvsTQAyje1fUj1I/s200/IMG_0764.JPG" width="200" /></a></td></tr>
<tr><td class="tr-caption" style="font-size: 13px;">Figure 4: OK button</td></tr>
</tbody></table>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiKUTrX6-yV5u_Egjlnd7Y8tHxs-P1Z5DcjK76eQ9NxvHmmSb2OdxW3lVSsq5kJh28MxdexW1-YIYY1OPaqDbicCcmoCZmpGGMEHeCJaeMEBwZBLEOlJ_7_fW7pPogRjIsHRk14Ks6sLSM/s1600/IMG_0765.JPG" imageanchor="1" style="clear: right; display: inline !important; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiKUTrX6-yV5u_Egjlnd7Y8tHxs-P1Z5DcjK76eQ9NxvHmmSb2OdxW3lVSsq5kJh28MxdexW1-YIYY1OPaqDbicCcmoCZmpGGMEHeCJaeMEBwZBLEOlJ_7_fW7pPogRjIsHRk14Ks6sLSM/s200/IMG_0765.JPG" width="200" /></a></td></tr>
<tr><td class="tr-caption" style="font-size: 13px;">Figure 5: Confirm button</td></tr>
</tbody></table>
<span style="text-align: justify;">Lastly the "power off" button requires a continuous press (Figure 6).</span><br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEju88JZf5A_dqOHoC6d4PJ0N_A94ihs5Nfzye0sC2e2K7DJKZN4kW8OUz1IJiGXti9PpDK5AiiM49k6LsakneTvzeJAhKT6E9d5f6XzQY8ggWu6JpPQoZ5FX-apBLNIA9b_VsCVdAW6b6g/s1600/IMG_0766.JPG" imageanchor="1" style="clear: right; display: inline !important; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEju88JZf5A_dqOHoC6d4PJ0N_A94ihs5Nfzye0sC2e2K7DJKZN4kW8OUz1IJiGXti9PpDK5AiiM49k6LsakneTvzeJAhKT6E9d5f6XzQY8ggWu6JpPQoZ5FX-apBLNIA9b_VsCVdAW6b6g/s200/IMG_0766.JPG" width="200" /></a></td></tr>
<tr><td class="tr-caption" style="font-size: 13px;">Figure 6: Power off</td></tr>
</tbody></table>
<br />
<div style="text-align: justify;">
<span style="text-align: justify;">Unfortunately the Alaris PK also has a few shortcomings. If one forgets to prime the pump when using remifentanil, it takes 7 minutes and 22 seconds before the pump alarms to tell you that a downstream clamp is still on. This means that there is a significant amount of time during which one may think that the pump is delivering a drug when it isn't. The video is a time-lapsed to show that after 5 minutes the pump is informing us that both the plasma concentration and effect site concentration have reached the set levels, however not a single drop of remifentanil has been delivered. A simple design change would involve the pump not allowing an infusion to be started without the pump first being primed.</span></div>
<span style="text-align: justify;"><br /></span>
<br />
<div class="" style="clear: both; text-align: justify;">
<div class="separator" style="clear: both; text-align: center;">
<iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dyxuai-6XMiEPrZ09k5KcfkdOTzfhbCRvucQLykhGvH4MYCvSG9gRIoniX599-uZfzT9iVLTGOw9MHZUw2l1g' class='b-hbp-video b-uploaded' frameborder='0'></iframe></div>
<br /></div>
<h4 style="text-align: justify;">
The suction on the anaesthetic machine</h4>
<div class="" style="clear: both; text-align: justify;">
The suction on an anaesthetic machine is used to remove body fluids such as airway secretions or gastric contents. It may have to be used in an emergency if the patient regurgitates gastric contents. On some anaesthetic machines the suction is placed next to the anaesthetic machine ON/OFF switch (Figure 7).<br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: justify;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhrFQADH9hdKxCzDXvxscTWVzNIvfKLWtz2hoB3nv6OeiWdz3Hvmd10jOuuKmGQ_vNIXI_lPuWPMytN55prhiHG9_RCYZnT96f13gbnQvc3hEC5Pu1_XNtM6GJe_qZnKMbCIIBTwSsGOGs/s1600/suction.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhrFQADH9hdKxCzDXvxscTWVzNIvfKLWtz2hoB3nv6OeiWdz3Hvmd10jOuuKmGQ_vNIXI_lPuWPMytN55prhiHG9_RCYZnT96f13gbnQvc3hEC5Pu1_XNtM6GJe_qZnKMbCIIBTwSsGOGs/s320/suction.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="font-size: 13px; text-align: center;">Figure 7: Tempting to switch the anaesthetic machine off by mistake</td></tr>
</tbody></table>
This means that a person may inadvertently switch off the anaesthetic machine when they meant to switch on the suction. Some anaesthetic machines allow you a grace period when you switch them off in case you have made a mistake and you can quickly switch them back on without them powering down. The anaesthetic machine pictured does not have this function. The manufacturer has instead installed a cover on the anaesthetic machine ON/OFF switch to ask as a physical constraint (Figure 8).<br />
<br /></div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEip7a4M1mb-zGdWi7Uil84SASnbS_OK4Xci-pmGiHA1yp180_qLnrcxC37I5oDbDUjGzyvapD0XvnC_n7hCcvUhizX7s3IhMyHtEq-9jwLDm1UcdWRX15fzXNf-pIKjhsNWeuyIAdWG3Tk/s1600/suction2.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEip7a4M1mb-zGdWi7Uil84SASnbS_OK4Xci-pmGiHA1yp180_qLnrcxC37I5oDbDUjGzyvapD0XvnC_n7hCcvUhizX7s3IhMyHtEq-9jwLDm1UcdWRX15fzXNf-pIKjhsNWeuyIAdWG3Tk/s320/suction2.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="font-size: 13px;">Figure 8: The clear plastic cap acts as a physical constraint</td></tr>
</tbody></table>
<div class="separator" style="clear: both; text-align: justify;">
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<div class="separator" style="clear: both; text-align: justify;">
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<h4>
The value of simulation</h4>
<div style="text-align: justify;">
Many devices undergo only limited testing by carefully selected end users. Very few devices are tested under stressful or crisis conditions. This means that devices can be released without ensuring that they will be used as intended by the manufacturer. Simulation could be used to test products in realistic conditions during the design stages, without the risk of patient harm.</div>
<div style="text-align: justify;">
In addition, simulation could be used to train personnel in the correct use of the equipment, ensuring that the actions are maintained under crisis conditions.</div>
<div style="text-align: justify;">
Simulation for equipment design and training is greatly under-utilised. If manufacturers collaborated with simulation centres, their devices could integrate affordances and constraints which would minimise human-equipment interaction errors.</div>
<div>
<br /></div>
<div>
<br /></div>
<div>
<br /></div>
Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com0tag:blogger.com,1999:blog-3508305836023632036.post-58223219132205159372015-05-01T14:50:00.001+01:002015-05-01T14:50:40.674+01:00Scottish Clinical Skills Network (SCSN) annual conference 2015: The great and the challenges (by M Moneypenny)<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrmKOPSyHK0OF6U3758LXbFSZefKCxm6rnMtebw_XSXLqMoPzTbjg63_zTWOmj00nUvwK9TSBJIUs5ITYiHnkUAltwRdfQ_7-V9x3iyb2IGdbBhr47E3ExBg8VB95dCfTlXchp-YWnVZs/s1600/vscocam-photo-1.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrmKOPSyHK0OF6U3758LXbFSZefKCxm6rnMtebw_XSXLqMoPzTbjg63_zTWOmj00nUvwK9TSBJIUs5ITYiHnkUAltwRdfQ_7-V9x3iyb2IGdbBhr47E3ExBg8VB95dCfTlXchp-YWnVZs/s1600/vscocam-photo-1.jpg" height="138" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Easterbrook conference centre, Dumfries</td></tr>
</tbody></table>
<div style="text-align: justify;">
<div style="text-align: justify;">
<span style="font-size: x-small;">Disclaimer: The author is vice-chair of the SCSN</span></div>
</div>
<h4>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
The great</div>
</h4>
<div style="text-align: justify;">
The SCSN conference provides a unique opportunity to network with like-minded people from across Scotland and further afield (there were delegates from England, Finland and the US). Although email has made the world smaller, as a speaker at a recent conference said: "Emailing is not 'having a conversation'". The SCSN conference allows everybody the opportunity to have a conversation, to explore areas of mutual interest, strengthen old ties and make new ones.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEheYAUoWZcJLXcseFBiYU7AYSnTNdDQU2hFj3sFA6yMt-Ojk7Oli6enHVMVW6HLA26dcYmY9_8CQ9JM_2hyphenhyphenYznAvNiux2a4jki2nEj33gwMzkUSbGkPNvH-A1kwxYfbnWx6muxIpMxgDMs/s1600/Screen+Shot+2015-05-01+at+14.33.12.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEheYAUoWZcJLXcseFBiYU7AYSnTNdDQU2hFj3sFA6yMt-Ojk7Oli6enHVMVW6HLA26dcYmY9_8CQ9JM_2hyphenhyphenYznAvNiux2a4jki2nEj33gwMzkUSbGkPNvH-A1kwxYfbnWx6muxIpMxgDMs/s1600/Screen+Shot+2015-05-01+at+14.33.12.png" /></a>The three keynote speakers approached clinical skills from very different angles and all three were worth the trip alone. Professor Hugh Barr, President of the <a href="http://caipe.org.uk/about-us/president-of-caipe/" target="_blank">Centre for Advancement of Interprofessional Education</a>, discussed interprofessional learning and teaching, the real benefits it provides and the challenges faced by those of us who deliver it. Professor Ken Walker, chair of the <a href="http://www.rcsed.ac.uk/education/scottish-surgical-simulation-collaborative.aspx" target="_blank">Scottish Surgical Simulation Collaborative</a>, discussed the need for innovation in a training unit, but cautioned against "too much storming, and not enough norming and performing." Professor Jennifer Cleland, chair of council at the <a href="http://www.asme.org.uk/senior-officers-trustees/professor-jennifer-cleland.html" target="_blank">Association for the Study of Medical Education</a>, talked about moving away from prior academic attainment for medical school admission as it is a poor predictor of post-graduate performance. She informed us that attempts to widen access to medical school have failed and she also discussed the differences between values (enduring beliefs) and personalities (enduring traits). </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
The social programme was the right mix between entertainment and networking, with whisky tasting, recitation of Burns' poems and a thought-provoking speech considering what "<a href="http://en.wikipedia.org/wiki/Robert_Burns" target="_blank">The Bard</a>" would have thought of the plight of the people trying to reach European shores from North Africa.</div>
<div style="text-align: justify;">
<br /></div>
<h4 style="text-align: justify;">
The challenges</h4>
<br />
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg3sJ1XIuyUT-FdKAd4iHJ-TkPKTwK6nRsghe8oFWKeY6itCX6IxcZb_VVxnCl_7VBtH58bB977k1xjs_hZFjbDF-Jk_CZceWKF-vV6EXTXu5T0eA-M80_BZzG9Ntw0dm2Z3HTVCNV5Nsk/s1600/scsn-logo.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg3sJ1XIuyUT-FdKAd4iHJ-TkPKTwK6nRsghe8oFWKeY6itCX6IxcZb_VVxnCl_7VBtH58bB977k1xjs_hZFjbDF-Jk_CZceWKF-vV6EXTXu5T0eA-M80_BZzG9Ntw0dm2Z3HTVCNV5Nsk/s1600/scsn-logo.jpg" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Strength through<br />
collaboration</td></tr>
</tbody></table>
<div style="text-align: justify;">
The strength of the network lies in its bottom-up grassroots nature, attracting members who are interested in clinical skills from across Scotland. The scope for collaboration is enormous. However the majority of the presentations and posters showcased research from a single institution. When research was collaborative, the most common partnership was between institutions in the same city (e.g. University of Aberdeen and Robert Gordon University, University of Glasgow and NHS GG&C). Notable exceptions were collaborations between the University of Aberdeen and the University of Ottawa, and a multi-agency exercise between the Scottish Fire and Rescue Service, the Scottish Ambulance Service, the Emergency Medical Retrieval Service and Yorkhill Children's Hospital. With a little planning it should be possible for much of the research to be carried out in multiple centres. This would take a bit more work but it would also make the results more robust, reduce the risk of repeating a similar (under-powered) study and improve the chances of asking the right questions in the first place. To encourage collaboration, future abstract submissions could have a weighting for multi-centre studies.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Minor IT issues meant that some speaker's slides were not displayed correctly and a laptop failure meant that some speakers were unable to display their slides at all. A policy of requesting all slides to be uploaded on the first day and a back-up laptop should be able to minimise these problems in the future.</div>
<div style="text-align: justify;">
<br /></div>
<h4>
Final thoughts</h4>
<div>
One of the most well-attended Scottish health conferences in recent years, the get-together in Dumfries shows the continued relevance of the SCSN to the development and promotion of clinical skills training. The next conference is in Aberdeen on the 20th-21st April 2016. See you there?</div>
Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com0tag:blogger.com,1999:blog-3508305836023632036.post-39380920158446938312015-04-27T12:59:00.001+01:002015-04-27T13:03:10.212+01:00Book of the month: Medical error and patient safety: human factors in medicine (Peters & Peters)<h4 style="text-align: start;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEifKNMLrEUJVHE2Gz9Bm1gUuXKUPhisRnRB9cbJMpKgxVTjXgQHrrWM3rGtZQc6dUPy3mznHJxr-bK_H5xjaqmJR4J-6h2JHjAPmFzFow2q3mpkkU-6DKy5kwDSIDxjv4eDpoPLT5qu0z4/s1600/MEPS.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em; text-align: justify;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEifKNMLrEUJVHE2Gz9Bm1gUuXKUPhisRnRB9cbJMpKgxVTjXgQHrrWM3rGtZQc6dUPy3mznHJxr-bK_H5xjaqmJR4J-6h2JHjAPmFzFow2q3mpkkU-6DKy5kwDSIDxjv4eDpoPLT5qu0z4/s1600/MEPS.jpg" height="200" width="127" /></a><span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><div style="text-align: justify;">
About the authors</div>
</span></h4>
<div>
<div style="text-align: justify;">
George and Barbara Peters are a father and daughter team. According to the included biography, George Peters is a multidisciplinary specialist, with experience as a safety specialist and as a design, reliability and quality engineer. Barbara Peters "has specialized in problem solving relating to medical error, safety, risk assessment, and environmental health hazards".</div>
<div style="text-align: justify;">
<br /></div>
</div>
<div>
<div style="text-align: start;">
<div style="text-align: justify;">
<h4>
Who should read this book?</h4>
</div>
</div>
</div>
<div>
<div style="text-align: start;">
<div style="text-align: justify;">
The authors state that this book is a basic textbook and reference manual "for those who may attempt to deal with and minimise medical error" (p.6). They go on to say that: "Most readers will have little difficulty understanding the discrete word phrases, simplified specialty language, unique concepts, and general suggestions for the improvement of patient safety by reducing medical error." (p.8) Unfortunately, as explained below, probably very few people should read this book.</div>
</div>
<div style="text-align: start;">
<div style="text-align: justify;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><br /></span></div>
</div>
<h4 style="text-align: start;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">In summary</span></h4>
<div style="text-align: start;">
<div style="text-align: justify;">
The book is divided into 9 chapters:</div>
<br />
<ol>
<li style="text-align: justify;">Introduction</li>
<li style="text-align: justify;">General Concepts</li>
<li style="text-align: justify;">Medical Services</li>
<li style="text-align: justify;">Medical Devices</li>
<li style="text-align: justify;">Analysis</li>
<li style="text-align: justify;">Human Factors</li>
<li style="text-align: justify;">Management Errors</li>
<li style="text-align: justify;">Communications</li>
<li style="text-align: justify;">Drug Delivery</li>
</ol>
</div>
<div style="text-align: start;">
<div style="text-align: justify;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);"><br /></span></div>
</div>
<h4 style="text-align: start;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">What's good about this book?</span></h4>
<div style="text-align: start;">
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: justify;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhchHSRkARTBOTVacY2BDfL2vvKCcEpieP7rX3Erx-DBUoWk25Q8UrN_qE8wXdZOr-hGCxLtO0zrda1v2t_q0SUBCrgkbpKBczmxaz0PNS8jOfWscFiZY0ThzDmYawzRsZEIMtHnVCm1P4/s1600/20140830_144022.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhchHSRkARTBOTVacY2BDfL2vvKCcEpieP7rX3Erx-DBUoWk25Q8UrN_qE8wXdZOr-hGCxLtO0zrda1v2t_q0SUBCrgkbpKBczmxaz0PNS8jOfWscFiZY0ThzDmYawzRsZEIMtHnVCm1P4/s1600/20140830_144022.jpg" height="180" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">The use of simulators for learning, practice, and refresher training <br />
might help in… emergency, crisis or rare event scenarios (p.20)</td></tr>
</tbody></table>
<div style="text-align: justify;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0); font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;">The authors mirror <a href="http://www.scotsimcentre.blogspot.co.uk/2014/02/books-of-month-why-hospitals-should-fly.html" target="_blank">Ronnie Glavin's question</a> regarding why there has been so little change since the 1999 report "To Err is Human", saying: "There was no magic remedy, only a seemingly complex and intractable human behaviour problem" (p.2). The authors call for an increase in transparency with respect to medical error, for the harmonisation of standards (e.g. US, EU, international)</span></div>
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0); font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;">The use of simulation and simulators is considered and recommended (e.g. see photo caption) including the use of simulation for resilience or stress-testing "intended to discover and correct weaknesses in the system so that a hardened or more robust organisation will result".</span></div>
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There is the occasional interesting concept, e.g. an "equal status" program instituted at some hospitals in which "all personnel are considered equal and a vital part of the team" (p.23) They also suggest the need for "error detectives" who are authorised to cross organisational boundaries and hierarchies and provide a direct feedback loop to management. The authors also argue for the need for civility and that it should "prevail under normal, stressful, and even extraordinary circumstances." They recommend being honest and advocate the 3R approach (Regret, Reason, Reparation) to apologies. They also call for HF studies to start at the product design stage. Chapter 9, Drug Delivery, covers a number of useful concepts such as the use of warning symbols, labelling, and prescription directions (such as the slightly unnecessary "Caution: This medicine may be taken with or without food" sticker on a Lisinopril container).<br />
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The caveats at the end of each chapter, rather than being caveats actually provide an overview of much of the covered material.</div>
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<h4 style="text-align: start;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">What's bad about this book?</span></h4>
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The almost total lack of a narrative or co-ordinated, logical approach to any of the chapters gives this book an "Alice in Wonderland" feel without the great prose. The examples are numerous: </div>
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<ul>
<li>The first sub-heading in "Intentional Bias"(p.15) is "Knee", the next is "Head"</li>
<li>In "Chapter 2: General Concepts", "Teamwork" (p.20) is stuck between "Harmonization" and "Rationalisation". </li>
<li>In "Chapter 3: Medical Services", "Innocent Errors" (p.24) is found between "Civility" and "Patient Involvement" (and, no, the headings are not arranged alphabetically)</li>
<li>In "Chapter 7: Management Errors", which covers errors due to poor supervision or management decisions, one of the subheadings is "Home Use Devices". This section makes no reference to management.</li>
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There is no overview at the beginning of each chapter and although t<span style="text-align: justify;">he authors claim to be providing a simplified language they write sentences such as:</span><br />
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"(Factor analysis) is primarily used to test the ranks of number matrices if statistical correlation coefficients are available and express a relationship between the variables" and</blockquote>
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"However, there have been dramatic changes or improvements in medical knowledge and procedural skills, medical equipment and devices, pharmaceutical efficacy and safety, higher social expectations from the medical profession, informed consent, animal rights, the intrusion of regulatory and legal concepts of social responsibility, complex payment schemes and practices, and rapid growith of medical organisationss that stress highly interactive group behaviour, financial outcomes, and business goals" (p.108)</blockquote>
The authors also make sweeping generalisations such as:<br />
<blockquote class="tr_bq">
"Research has illustrated that there is considerable effort in some areas to locate surface antimicrobial agents" (p.42)<br />
"All (hospital) hardware should be compatible with the limited capabilities of the aged, infirm, sick, and disabled" (p.53)<br />
"Criticism is to be expected during periods of rapid transition. The ideal will become the reality." (p.54)<br />
"Special training may be necessary to prevent situation awareness errors." (p.103)<br />
"A radiating positive attitude should be displayed by managers." (p.140)</blockquote>
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Puzzling sentences abound such as "Patients may have special childhood problems such as foreign objects stuck in the throat, respiratory tract, or other body openings. These objects may also include food, bones, nuts, or vegetables not properly chewed" </div>
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">And the occasional unnecessary fact is thrown into the mix: "When competing goals, such as fairness versus self-interest, are present, the brain areas involved and activated are the anterior insula and the right dorsolateral prefrontal cortex."(p.149) and "What may be surprising is that long-term potentiation is first induced in the hippocampal area... fast neuron-glia synaptic transmission has been found between CA1 hippocampal neurons and NG2 macroglial synapses" (p.167-168)</span><br />
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<h4 style="text-align: start;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">Final thoughts</span></h4>
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In the Preface, the authors state that they tried to eliminate bias in the book: "There was no third-party direction or control." (p. xvi) Unfortunately this is exactly what the book is lacking, some sort of coordinating entity which might turn this, at times rambling, book into a worthwhile read. The book's title "Medical Error and Patient Safety: Human Factors in Medicine" seems to have been applied in retrospect and none of the subjects is well-covered. In its present form this book should be given a wide berth. </div>
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Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com0tag:blogger.com,1999:blog-3508305836023632036.post-75756285081328787322015-03-27T08:11:00.000+00:002015-03-27T08:11:44.751+00:00Flight 4U 9525 and the dynamic Swiss cheese model<div style="text-align: justify;">
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; text-align: justify;"><tbody>
<tr><td style="text-align: center;"><a href="http://commons.wikimedia.org/wiki/File%3ASwiss_cheese_model_of_accident_causation.png" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;" title="By Davidmack (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons"><img alt="Swiss cheese model of accident causation" height="134" src="//upload.wikimedia.org/wikipedia/commons/thumb/e/e8/Swiss_cheese_model_of_accident_causation.png/512px-Swiss_cheese_model_of_accident_causation.png" width="200" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">The Swiss cheese model</td></tr>
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James Reason's <a href="http://en.wikipedia.org/wiki/Swiss_cheese_model" target="_blank">Swiss cheese model</a> explains how successive layers of defences can be breached, or weaknesses can line up, in order for an incident to occur.</div>
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The traditional depiction of the model is of a static succession of slices of cheese. In this model, closing one of the holes in the sequence prevents the incident.<br />
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A better way of visualising the concept is by thinking of a dynamic Swiss cheese model (see video). The weaknesses are not static and closing one weakness may cause another to open elsewhere in the same (or another) "slice".<br />
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<iframe width="320" height="266" class="YOUTUBE-iframe-video" data-thumbnail-src="https://i.ytimg.com/vi/EB2mKsWedJ0/0.jpg" src="http://www.youtube.com/embed/EB2mKsWedJ0?feature=player_embedded" frameborder="0" allowfullscreen></iframe></div>
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<h4>
Flight 4U 9525</h4>
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The exact circumstances of the crash of the Germanwings Airbus 320 on the 24th of March 2015 have yet to be established. However it seems likely that <a href="http://www.bbc.co.uk/news/world-europe-32072218" target="_blank">the co-pilot intentionally flew the plane into the ground</a>. The captain had probably left the flight deck to use the toilet and was then locked out of the cockpit by his first officer.</div>
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<h4>
Post-9/11 cockpit doors</h4>
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After the 9/11 terrorist attacks, cockpit doors were reinforced in order to prevent forced access. In terms of the Swiss cheese model, this weakness was therefore reduced. Crew could still access the cockpit if the pilot had become incapacitated by entering a keypad code. However, if the pilot was not incapacitated he or she could override the keypad system. Therefore a terrorist in possession of the code could still be prevented from getting into the cockpit.</div>
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<h4>
The dynamic Swiss cheese model</h4>
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The closing of the weakness in the structural/system layers allowing terrorists access to the cockpit opened a weakness in the set of circumstances where someone may want to access the cockpit for legitimate reasons against the flight crew's wishes. After the loss of Malaysia Airlines flight MH370, Popular Mechanics wrote <a href="http://www.popularmechanics.com/flight/a10270/in-light-of-mh370-evidence-could-plane-cockpits-be-too-secure-16611747/" target="_blank">a prescient article</a> in March 2014 asking "Could Plane Cockpits Be Too Secure? Should pilots be allowed to lock themselves in the cockpit?" After the crash of Flight 4U 9525, in an attempt to close this new weakness, many airlines are now requiring the presence of two crew members on the flight deck at all times. It is unclear what new weaknesses this policy will create.</div>
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<h4>
Lessons for the rest of us</h4>
Measures put in place in response to an incident will almost inevitably increase the risk of other, unforeseen incidents occurring. Time spent carrying out analyses and simulations of possible side-effects of the "fix" may allow us to minimise these new weaknesses.</div>
Michaelhttp://www.blogger.com/profile/01436383305280903719noreply@blogger.com0