SUSP Implementation Phase:
Learning From Defects Through
Sensemaking II
Bradford D. Winters, Ph.D., M.D., FCCM
Associate Professor
Anesthesiology and Critical Care Medicine and Surgery
Core Faculty Armstrong Institute for Patient Safety and Quality
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Polling Questions
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What is your role?
Have you established your SUSP team?
Has your team started meeting regularly?
Is your team already working on specific defects?
Where are you from? Enter organization in the chat box.
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Learning Objectives
• Use the Learning For Defects (LFD) tool to
perform second-order problem solving
• Create an action plan to address prioritized
contributing factors
• Evaluate the effectiveness of your intervention by
measuring baseline and post-intervention
performance
• Present your findings to surgical department
leadership
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Learning from Defects
What happened?
From view of person involved
Why did it happen?
How will you reduce it happening
again?
How will you know the risk is
reduced?
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Communicating for Patient Safety
CASE STUDY: RENAL TRANSPLANT
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Case Study: Renal Transplant
Setting the stage
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Who:
What:
When:
Where:
And:
An ICU patient bleeding after renal transplant
Needs emergency surgery to correct
Early morning 0530
Taken to OR by anesthesiology team
Nurse hands over chart with Kardex stamp plate as
patient is on the way out of ICU
What happened next?
• In OR:
Patient unstable on arrival to OR at 0600, necessitating
additional lines
• In OR:
Patient stabilized and surgery begins
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Case Study: Renal Transplant
• Attending anesthesiologist called to an emergent neurosurgical case
for craniotomy
• Attending leaves renal transplant case, returns at 0730
• Meanwhile, nursing and OR tech staff turned over at 0700
• Anesthesiology resident who started the case has already signed
out to the day shift resident who has taken over
• Attending notes that a transfusion has started, and that the PRBCs
bag has the wrong patient’s name
• Attending immediately stops the transfusion, reporting error to the
OR staff and blood bank
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Case Study: Renal Transplant
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Resident used the stamp plate to order and then check the blood
However, wrong chart sent with the patient from the ICU
Never checked against the wrist band
All of the OR documents stamped with the name from the incorrect
chart
• Ultimately, the patient dies, though transfusion not the cause as the
donor blood was type O
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Case Study: Renal Transplant
Learning from Defects Tool
• How will you reduce the risk of the defect
happening again?
• How will you know the risk is reduced?
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Case Study: Renal Transplant
System Failures
Knowledge, Skills & Competence
Anesthesiology attending not notified of the
transfusion; wrist band checks with stamp
plate were not done at multiple points
Opportunities For Improvement
Create independent
checks, encourage patient
safety culture initiatives,
add system constraints like
barcoding technologies
Unit Environment
Near simultaneous emergent events; change
of two different provider groups at same
time; no independent check
Stagger staff changes
Formalize hand-offs
between departments
Other Factors
Hospital environment: Transfer across units
Patient characteristics: High acuity
Task characteristics: Blood check-in only as
good as existing identity documents
Ensure hand-off process
supports emergencies
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How Will You Reduce Risk Reoccurring?
Pick a contributing factor to address first
• What is its impact on causing the defect?
• Does it occur rarely or have a high likelihood of reoccurring?
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How Will You Reduce Risk of Happening Again?
Create choices by brainstorming possible interventions
• Involve the entire team with flipcharts and post-its
• Prioritize most important contributing factors and most beneficial
interventions
• Take advantage of your diverse team!
– Senior Executive’s big picture view of the organization and knowledge
of resources
– Team members’ connections throughout organization
– Frontline staff with particular insight into the defect
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How Will You Reduce Risk of Happening Again?
Make choices and select your intervention
• Have your team vote on its favorite solutions
• Consider rating solutions based on direct and
feasible way to address the defect
Weaker
Intermediate
Stronger
Telling someone to
be more careful
Eliminating or
reducing
distractions
Making a
process or device
“mistake proof”
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Building Resiliency into Intervention
Not all interventions are created equal
Forcing functions and constraints
Strongest
Automation and computerization
Standardization and protocols
Checklists and independent check systems
STRENGTH OF
INTERVENTION
Rules and policies
Education and information
Weakest
Vague warnings – Be more careful!
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Not All Education Is Created Equal Either
Strive for Concise, Clear and Relevant Messages
• Avoid information overload in all manners of
disseminating information
• Share a concise message with a clear focus
relevant to specific audience needs
• Experiential learning with hands-on approach
will be far more effective at motivating change
than an automated email dense with data
Email
Blast
Lecture
Handson
Training
Team
Meetings
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How Will You Reduce Risk of Happening Again?
Remember the people side of the intervention
• Consider who influences and impacts your intervention
• Are they likely to support or resist your intervention?
• Create an action plan to get them on board
Stakeholder
Action Plan to
Engage
Lead Point on
Action Plan
Follow-up Date
for Lead to
Report to Group
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How Will You Reduce Risk of Happening Again?
Engagement is hard!
• Use the wisdom of your diverse team to overcome barriers
and solve problems
• Make sure the intervention details are spelled out and
understood by everyone
• Ensure the intervention is carried out consistently
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How Will You Know Risks Were Reduced?
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Do staff know about the interventions?
Are staff using the interventions as intended?
Do staff believe risks were reduced?
Subjective evaluations can provide valuable
information
• Data driven metrics should be the goal whenever
possible
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How Will You Know Risks Were Reduced?
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Identify how you will measure success
Put an audit plan in place to track that measure
Include a way to feed data back to your group
Review your audits and adjust your intervention as needed
May require revisiting Learning from Defects process
Tip: Learning from defects is a continuous process as is the need
to engage frontline staff.
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How Will You Know Risks Were Reduced?
• Evaluate the effectiveness of your intervention by
measuring baseline and post-intervention
performance
• Present your findings to surgical department
leadership
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How Will You Know Risks Were Reduced?
Plan
Measure
of Success
Who
Measures
and How
Often
Where
Recorded
Follow-up
Date
Corrective
Action
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Ongoing Key Questions (SSA)
Your Mantra!
Patient safety culture requires constant vigilance
How is the next patient
going to be harmed?
What can I do to
prevent that harm?
Tip: Remember that the Learning from Defects tool addresses
both technical tasks and adaptive teamwork issues.
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Polling question – Staff Safety
Assessment (SSA)
• Have you asked your frontline staff the two questions?
– Yes
– No
• How often do you ask the two questions?
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Never
At least once a year
At least once a quarter
At least once a month
Every week
The SSA questionnaire is available at all times
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Polling question – Staff Safety
Assessment (SSA)
• Do you check the responses to the two
questions regularly?
– No, we forget to check for responses.
– No, not regularly. We tend to check when we are
ready to work on a new defect.
– Yes, at least quarterly
– Yes, at least monthly
– Yes, at least weekly
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Action Plan
• Review the Learning from Defects tool with your
team
• Review a defect in your operating rooms
• Select one defect per month
• Consider using in surgical morbidity and mortality
conferences
• Post the stories of reduced risks (with data!!)
• Share with others
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References
Bagian JP, Lee C, et al. Developing and deploying a patient safety program in a large health
care delivery system: you can't fix what you don't know about. Jt Comm J Qual Improv
2001;27:522-32.
Pronovost PJ, Holzmueller CG, et al. A practical tool to learn from defects in patient care. Jt
Comm J Qual Patient Saf 2006;32(2):102-108.
Pronovost PJ, Wu Aw, et al. Acute decompensation after removing a central line: practical
approaches to increasing safety in the intensive care unit. Ann Int Med 2004;140(12):10251033.
Reason J. Human Error. Cambridge, England: Cambridge University Press, 2000.
Vincent C, Taylor-Adams S, Stanhope N. Framework for Analyzing Risk and Safety in Clinical
Medicine. BMJ. 1998;316:1154.
Wu AW, Lipshutz AKM, et al. The effectiveness and efficiency of root cause analysis. JAMA
2008;299:685-87.
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