Patient Safety and Quality 8 February 2013 Ralph T. Soule, Captain, US Navy, retired Division...
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Transcript of Patient Safety and Quality 8 February 2013 Ralph T. Soule, Captain, US Navy, retired Division...
Patient Safety and Quality8 February 2013
Ralph T. Soule, Captain, US Navy, retiredDivision Director
Aircraft Carrier Test, Evaluation, and Certification Naval Sea Systems Command
High Reliability for Patient SafetyHigh Reliability for Patient Safety
DISTRIBUTION STATEMENT A: Approved for public release; distribution is unlimited.
Presentation Name Patient Safety and Quality8 February 20132
Submarine Maintenance and Medical Care
Similar Attributes
Highly regulated Safety is essential –
severe consequences for failure
Operating environments are inherently hazardous
Complex, interdependent systems
People play a critical role in complex processes
Highly reliable, long-term operations are essential
Learning from experience is essential
Presentation Name Patient Safety and Quality8 February 20133
Most of our “patients” don’t really want to see us
Our families have no idea what we’re talking about when we discuss work
We use a lot of hoses, gases, and electrical connections in our work
When something gets in our way, we just make an “incision” to move it
Workers wear strange clothing
Submarine Maintenance and Medical Care
Similar Attributes
Presentation Name Patient Safety and Quality8 February 20134
Submarine Maintenance and Medical Care
Differences
Ship’s cannot “elope” from shipyards
Shipyard maintenance involves teams of hundreds, up to thousands of people
Shipyard managers and engineers never say “this won’t hurt a bit”
The “patient” is awake the whole time and often gives us instructions to help us do the job “better”
Presentation Name Patient Safety and Quality8 February 2013
Presentation Name Patient Safety and Quality8 February 20136
Outline
History - Loss of THRESHER
High Reliability Lessons: Submarine Safety (SUBSAFE) and other maintenance processes
Applications to Medical Care
Presentation Name Patient Safety and Quality8 February 20137
Early Submarine LossesSubmarines Lost 1915-1963
17 submarines lost to non-combat causes
1915: USS F-4 (SS-23)1917: USS F-1 (SS-20)1920: USS H-1 (SS-28)
USS S-5 (SS-110)1923: USS O-5 (SS-66)1926: USS S-51 (SS-162)1927: USS S-4 (SS-109)1939: USS SQUALUS (SS-192)1941: USS O-9 (SS-70)1942: USS S-26 (SS-131)
USS R-19 (SS-96)1943: USS R-12 (SS-89)1944: USS S-28 (SS-133)1949: USS COCHINO (SS-345)1958: USS STICKLEBACK (SS-415)1963: USS THRESHER (SSN-593)1968: USS SCORPION (SSN-589)
470 Lives Lost
Presentation Name Patient Safety and Quality8 February 20138
Laid down, 28 May 1958, at Portsmouth Naval Shipyard, Kittery, ME.
Launched on 9 July 1960.
13th nuclear powered attack submarine.
The first ship of its Class; leading edge of US submarine technology:
combining nuclear power with modern hull design
newly-designed equipment and components
USS THRESHER (SSN-593)
USS THRESHER launching ceremonies at the Portsmouth Naval Shipyard, Kittery, Maine, 9 July 1960.
She was fast, quiet, and deep diving
Presentation Name Patient Safety and Quality8 February 20139
Submarine Buoyancy and Ballast Tanks
On April 10, 1963, while engaged in a deep test dive, approximately 200 miles off the northeastern coast of the United States, the U.S.S. THRESHER (SSN-593), was lost at sea with all persons aboard - 112 naval personnel and 17
civilians.
THRESHER wreckage: About 200 miles off Cape Cod in 8,400 ft of water
PNSY
Presentation Name Patient Safety and Quality8 February 201311
Presentation Name Patient Safety and Quality8 February 201312
Navy Response to Loss of USS THRESHER
Immediately limited diving depth of all submarines
Court of Inquiry THRESHER Design
Appraisal Board Focus:
Design Construction Operation
Testimony Before Congress
Presentation Name Patient Safety and Quality8 February 201313
Investigation Conclusions
Loss ofpropulsion
power
Flooding in the engine room Unable to secure
from flooding
Spray on electricalswitchboards
Unableto blow
ballast tanks
Presentation Name Patient Safety and Quality8 February 201314
SUBSAFEPROGRAM
LOSS ofTHRESHER
Overhaul/Construction
MAINTENANCEPROCESSCHANGES
Inception of the SUBSAFE and Significant Culture Change
Presentation Name Patient Safety and Quality8 February 201315
Key Lessons
“The loss of the Thresher should not be viewed solely as the result of failure of a specific braze, weld, system, or component, but rather should be considered a consequence of the philosophy of design, construction, and inspection … it is important that we reevaluate our present practices where, in the desire to make advancements, we may have forsaken the fundamentals of good engineering. ” – ADM Rickover
Presentation Name Patient Safety and Quality8 February 201316
• Safety must be part of process design, not an afterthought• Key systems were under-designed for knowable risks• Failure to bound an unexpected problem• An attitude that specifications were merely goals, did not need
to be taken literally, and HQ permission not needed for failure to meet them
• Impact of accumulated conditions, not a single failure• The Navy had not updated its way of doing business to meet
the requirements of updated technology and high-performance ships that could operate in riskier environments
• Processes are only as good as their audit plan
Key Lessons
Presentation Name Patient Safety and Quality8 February 201317
Navy High Reliability Practices Applied to Health Care
It is expensive and costly to wait for mistakes to learn Use existing debriefing records to tune awareness
Safety is created in the moment, where work is done, by the people doing it “High reliability is a continuous, ongoing, dynamic
accomplishment." The blindness of hindsight bias short
circuits learning ...
Presentation Name Patient Safety and Quality8 February 2013
Getting it Wrong
Presentation Name Patient Safety and Quality8 February 201319
• Checklists• Work Model: training,
procedures, supervision• Critiques/Fact Sheets• Risk Management• Audits/Surveillances• Pre-operative safety briefings• Post-event/procedure debriefs
Navy Maintenance Tools for Medical Care
Presentation Name Patient Safety and Quality8 February 201320
• Key: interactivity among participants• Overview of procedure, team members, risks,
constraints, anomalies, expected outcomes• Each person
• Name• Role• What they need (from whom)• What they provide (to whom)• Reports to make (exact phraseology is important)• Reports needed• What was learned from last time
• Mostly likely problems and responses (what ifs?)
Pre-evolution briefs
Presentation Name Patient Safety and Quality8 February 201321
• Key: capturing each person’s perspective, follow up
• Was the desired outcome achieved?• Things to do more often• Things not to do next time• Hazards caught (which ones remain open?)• Assess work process tools (effectiveness/utility
of pre-briefs, procedure, especially things not covered, but should be, training/qualifications -> management credibility rests with follow up)
• What were the surprises and how were they identified?
• Things to do differently next time
Post-action reviews (informal)
Presentation Name Patient Safety and Quality8 February 201322
ACCIDENT
TIME
SA
FE
TY
L
EV
EL
Minimum
Optimum
Understanding the Challenge
- Actual
- Perceived
THE BATTLETHE BATTLEWHERE YOU THINK YOU ARE
WHERE YOU REALLY ARE
Presentation Name Patient Safety and Quality8 February 2013
Presentation Name Patient Safety and Quality8 February 201324
“Those who cannot remember the past are
condemned to repeat it.”
- George Santayana
“A good pre-event briefing beats an accident
investigation any day.”
- ADM Kinnaird R. McKee
Presentation Name Patient Safety and Quality8 February 201325
Questions