Challenges to Learning Patient Safety Events in Complex

Challenges to Learning: Patient Safety Events in Complex systems Patient Safety Event Learning Seminar Deer Lodge Centre, Winnipeg, MB November 2, 2010

Challenges to Learning: (forget about complex systems) The usual suspects: – Fear of consequences – Fear of the law – Lack of controls (as in cybernetics) – Messy mental models – Learning anaphylaxis

Challenges to learning: Fear of consequences – From the facility – where is the Just and Trusting Culture policy? – From the department – where is the inter-disciplinary support and commitment to learning? – From the unit – what will and won’t be used in performance management assessments? (back to the J+T Culture thing) – From colleagues – how we do things around here?

Challenges to learning: Fear of the law: – “Blueprint” for litigation – PHIA-noia – FIPAA-bility – Bogeyman of the criminal charges – Do you like to gamble? (1/13 versus 1/160, 000)

Challenges to learning: Lack of controls (cybernetics gone wild): – Feedback to staff – why bother reporting? – Feedback to patients/families – why bother trusting? – “Feed forward” to other units – why wash “dirty laundry”? – “Feed forward” to anybody who is interested – the problem of the big bad internet?

Challenges to learning: Messy mental models: • Variation of “if it walks like a duck and looks like a duck…” • Using linear (or occasionally epidemiological) models to understand the events • Searching for certainty – “We can’t be sure that the infection led to the patient’s demise, so we can’t consider this a critical incident…. ” • Homage to Rene Descartes

Challenges to learning: Learning anaphylaxis: – Is the facility a learning organization? – Is the department a learning department? – Is the unity a learning unit? – Three cheers for today’s session!!

Challenges to learning: In a complex system Healthcare is a complex system: – Probably a hybrid compared to other complex systems – Open versus closed system – Complex adaptive system (NDS) – dynamic nature – Complex socio-technical (or T-S) system – love the technical stuff – Basically a mysterious beast – the case of the dog that didn’t bark in the night…

Challenges to learning: In a complex system Some surprising elements: – Nonlinear causation – Emergent versus resultant properties – The importance of context – holistic approach – The system has a history – Relationships between components more important than the components themselves

Challenges to learning: In a complex system All of this requires: – Different ways of thinking to recognize learning opportunities – Different ways of reviewing/investigating events to promote understanding – Different ways of talking about events to promote active and applicable learning – (Sounds like hard work…. it isn’t)

Challenges to learning: In a complex system Questions? Contact info: Robson Healthcare system Safety Advisor rrobson@hssa. ca 519 -846 -2872 1 -877 -405 -9313