Believe what you see or see what you Richard Cook
NFO Conference: Att lära av varandra Södertälje stadshus 3-4 Februari 2015 The good surgeon believes what he sees. The bad one sees what he believes. Seeing and believing Good results come from experience. Experience comes from bad results. Richard I. Cook, MD Professor of Healthcare System Safety School of Technology and Health Royal Institute of Technology Huddinge, SWEDEN Copyright © 2015 by R.I.Cook for CTL Copyright © 2015 by R.I.Cook for CTL Key idea • Why do we continue to have accidents? • Why don’t we have more? Available free at www.ctlab.org Copyright © 2013 by R.I.Cook for CTL Rasmussen’s system model Rasmussen’s system model Operating point Accident Copyright © 2013 by R.I.Cook for CTL Copyright ⓒ 2015 by Richard I. Cook, MD Copyright © 2013 by R.I.Cook for CTL 1 All rights reserved. NFO Conference: Att lära av varandra Södertälje stadshus 3-4 Februari 2015 Rasmussen’s system model Rasmussen’s system model MARGINAL BOUNDARY ACCIDENT BOUNDARY ACCIDENT BOUNDARY Counter-gradient •New rules •Recent accidents •Safety campaigns The operating point tends to move towards the accident boundary Getting close to the margin is a signal that the operating point needs attention. What is to be done? Copyright © 2014 by R.I.Cook for CTL Copyright © 2013 by R.I.Cook for CTL Rasmussen’s system model Rasmussen’s system model Why doesn’t this lead to safe operations? We usually don’t know where the accident boundary is. ACCIDENT BOUNDARY MARGIN Copyright © 2013 by R.I.Cook for CTL Copyright © 2013 by R.I.Cook for CTL Rasmussen’s system model Rasmussen’s system model Normalization of deviance… The result is often a slipping of the operating point towards the accident boundary. Dianne Vaughn ACCIDENT BOUNDARY …moves the marginal boundary closer to the accident boundary. This is “flirting” with the margin Copyright © 2013 by R.I.Cook for CTL Copyright ⓒ 2015 by Richard I. Cook, MD Copyright © 2013 by R.I.Cook for CTL 2 All rights reserved. NFO Conference: Att lära av varandra Marginal boundary Accident boundary Blunt end view (B) Södertälje stadshus 3-4 Februari 2015 SAFETY nd rp e Sha w (S) vie Marginal boundary Accident boundary OPPORTUNITY Operating point ETY SAF ARD HAZ Experiments in search of more efficient operations Copyright © 2015 by R.I.Cook for CTL Copyright © 2015 by R.I.Cook for CTL Rasmussen’s system model ecology case: “soft” emergency What is surprising is not that there are so many accidents... Cook & Nemeth, Taking things in one’s stride”, Hollnagel et al., RE: Concepts and Precepts ③ OR SUITE 1 2 3 12 ② ① ..it is that there are so few! • how sick is this patient? • what else do I have to do today? • what leverage do I have? • how do I maintain good • why is it an emergency? • consequence of bumping a room for today’s work? • what leverage do I have • how do I maintain good anesthesiologist relationship with all the Ss? But why? Deeper knowledge •how long to get the patient to the OR? •how long before a room becomes empty? •how fast is this surgeon? •what else is pending? •how truthful is S? Deeper dependency •nurse & anesthesia staffing •different room geometries •precedents and policies •other obstacles Copyright Copyright © 2006 by R.I.Cook for CTL © 2013 by R.I.Cook for CTL ecology surgeon 1. demand 2. negotiation 3. agreement relationship with A? • what are the rules? Deeper knowledge • how will the patient’s condition change with time? • what happens if I don’t push hard • what is happening in the other ORs? • how long to get the patient to the OR? Deeper dependency •resident staffing room geometries •different •precedents and policies •other obstacles deep socio-technical structure Copyright © 2013 by R.I.Cook for CTL ecology case: “soft” emergency Cook & Nemeth, Taking things in one’s stride”, Hollnagel et al., RE: Concepts and Precepts R is multiply contingent variable time scales • resilience is a property of the system • resilience arises from system ecology molecular physics anesthesiologist surgeon patient hospital characteristics resources human professional roles physiology national funding actions anesthesiologist relies upon exploits defends disputes surgeon Resilience manifests at one scale Resilience involves all the scales deep socio-technical structure Copyright © 2013 by R.I.Cook for CTL Copyright ⓒ 2015 by Richard I. Cook, MD time (seconds) Copyright © 2013 by R.I.Cook for CTL 3 All rights reserved. NFO Conference: Att lära av varandra Södertälje stadshus 3-4 Februari 2015 Conclusions ecology Copyright © 2013 by R.I.Cook for CTL Medical work system is • complex • dynamic • adaptive Every part of the system is adapting all the time. Performance is much better than it should be. We have fewer catastrophes than expected. The system operates at the edge of failure. It is too expensive not to do so. We rely on resilience. It is already present in your work system. Challenge 2014-2020: Invest in resilience You are our only hope. Copyright © 2013 by R.I.Cook for CTL Copyright © 2013 by R.I.Cook for CTL Copyright ⓒ 2015 by Richard I. Cook, MD 4 All rights reserved.
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