Tuesday, October 6, 2009

Serious About Safety

On Monday, our leadership team spent the morning review Serious Safety Events and learning about how to conduct a Common Cause Analysis (CCA). In the past year, Ascension Health’s leaders established a new direction that would build on the successes of the Call to Action for Healthcare that is Safe: Healing without Harm by 2014.

We discussed three types of Human Errors*:

Skill-Based (Auto-Pilot Mode): Errors made when performing acts or tasks that require limited or no thought attention

Rule-Based (If-Then Response Mode): Errors made when performing acts or tasks that require application of rules – accumulated through experience and training – to familiar situations.

Knowledge-Based (Figuring-It-Out Mode): Errors made when performing acts related to new or unfamiliar situations that require problem solving and for which a rule does not exist or is not known.

*based on the Skill/Rule/Knowledge classification of Jens Rasmussen and the Generic Error Modeling System of James Reason

It was interesting to know that for every Serious Safety Event, we should probably see 1,000 precursor events or near-misses (a "near-miss" is defined as any process variation in our health care delivery that could have led to an adverse outcome or sentinel event but for any number of reasons, did not).

An example of how to improve was around avoiding employee injuries and what industries and companies we should model (e.g., Fed Ex because of their heavy lifting in handling packages).

Back to the run…The car just stopped short of hitting us though Dr. Mark had his hands on the car and shared the importance of the stop sign with the driver (he risked his life to make a point—something I do not recommend for other runners). I would certainly consider this a “near-miss.”

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