kLash Organization Talk1 - AAPM
Transcript of kLash Organization Talk1 - AAPM
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Or
Quality and safety must be prioritieswithin Radiation Oncology. within
and safety must be priorities within Radiation Oncology.
ation Oncology.•
PAST Current Future
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KL2014 2
To Err Is Human
14 years
Since report “To Err Is Human”
(Kohn, Corrigan, and Donaldson 2000)
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KL2014 3
Are we improving?
Operations on the wrong patient or the wrongbody part continue to take place, perhaps as often
as 50 times per weekin the United States
(estimated from: Minnesota Department of Health2013).
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KL2014 4
What Type of Organization Leads to a Safety Culture
• http://you http://youtu.be/8NPzLBSBzPItu.be/8NPzLBSBzPI
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KL2014 5
Safety Culture
“…the attitudes, beliefs, perceptions and values that employees share in
relation to safety…”
Cox, S. & Cox, T. (1991) The structure of employee attitudes to safety ‐ a European example Work and Stress, 5, 93 ‐ 106.
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Organization
Positive Safety Culture Characteristics
• Mutual trust • Shared perceptions of the importance of
safety • Confidence in efficacy of preventive
measuresHSC (Health And Safety Commission), 1993. Third report: organizing for safety. ACSNI Study Group on Human Factors. HMSO, London.
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KL2014 7
Past
There was fear of reporting incidents…
WHY?
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KL2014 8
Beginning of Time - 1980’s
• Few incidents were reported• Technology was simple-few computers• Cobalt, Ortho and Single Energy Accelerators• AP/PA• Hand Placed Blocks• Hand Calcs -Few computer• Near Misses were rarely thought about• No record and verify systems
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KL2014 9
Beginning of Time - 1980’s
• Wrong field size• Wrong time set• Wrong distance• Wrong blocks• Wrong decay factor• Source may get stuck• Bad skin reactions
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KL2014 10
Event Log of 1990
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KL2014 11
Would Record and Verify Help?
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KL2014 12
2005 Variance Report Form
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KL2014 13
Current
•Leadership
•Safety Culture
•Robust reporting system
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KL2014 14
Are we getting better?Are we having same problems nationally?
1990
Wrong Field sizeWrong MUWrong EnergySSDDot Grad InWrong BlockWrong plan usedWrong Calculation of MUWrong immobilizationNo bolus
20021980
Wrong field sizeWrong time setWrong distanceForgot blocksWrong decay factorSource may get stuck
2014
Wrong siteReference points drawn wrongBolus left outNo breath holdNear misses with system errorsWrong iso
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KL2014 15
Variance Workgroups
Purpose:
1.Review all variance’s 2. Identify priority 3. Conduct root cause analyses 4. Recommend changes to process 5. Look for common causes and trends
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KL2014 16
Membership of Variance Workgroups
Include Members From all Areas
• Scheduling• Simulation• Dosimetry/Physics• RTT• Faculty and Administration
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KL2014 17
Safety Organization
Radiation Treatment Delivery is Complex:
• Standard QA – Common Errors• Errors such as machine dose• Misalignments of the patient• Scheduling is complex• Many handoffs• What errors are not being caughtJt Comm J Qual Patient Saf. Jul 2011; 37(7): 291–299.
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KL2014 18
Incident Detailed Review
“Errors, whether reaching the patient or a workflowissue not reaching the patient, are often
multifactorial and require a detailed review in order to avert or at least minimize future errors…”
Workflow Enhancement (WE) Improves Safety inRadiation Oncology: Putting the WE and Team
TogetherSamuel T. Chao, MD,*,y
Tim Meier, RTT,* Brian Hugebeck, RTT,*Chandana A. Reddy, MS,* Andrew Godley, PhD,* Matt Kolar, MS,*
and John H. Suh, MD*,*Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; and
Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland Clinic, Cleveland, Ohio
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KL2014 19
High-Reliability Organizations (HROs)
“Collective Mindfulness”
(Weick and Sutcliffe 2007).
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KL2014 20
What is Reliability?
“Reliability depends on the lack of unwanted, unanticipated, and unexplainable
variance in performance…”
• -Eric Hollnagel, 1993, p. 51
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KL2014 21
High Reliability Systems
1. Preoccupation with failure2. Reluctance to simplify interpretations3. Sensitivity to operations4. Cultivation of resilience5. Willingness to organize around expertise
Karl E. Weick & Kathleen M. Sutcliffe, “Managing the Unexpected,”Jossey‐Bass, 2001
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KL2014 22
Future Organizations
• Hire Problem solvers• Spend time training staff• Understand that a safe culture will report 4-
5 variances per week• Decide should we focus on problem
variances or near misses?• Include patients with our safety initiatives
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KL2014 23
Brainstorming for the FUTURE
• Hiring a Safety Officer or a lead to storm and investigate
• Continue to report and review utilizing all Systems
• Review National Data-RO-ILS
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KL2014 24
Air Travel, Nuclear Power, Amusement Parks
Air Travel, Nuclear Power, Amusement Parks…
Have become“high reliability”
(Reason 1997; Weick and Sutcliffe 2007).
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KL2014 25
Organization
A well-designed organization is not a stable solution to achieve, but a developmental process to keep active.
(Starbuck & Nystrom, 1981, p. 14)
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KL2014 26
In the US, operations on the wrong patient or the wrong body part take place as often as…
20%
20%
20%
20%
20% 1. 50 times per year2. 50 times per week3. 20 times a day4. 150 times a week
10
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KL2014 27
In the US, Operations on the wrong patient or the wrong body part take place as often
20%
20%
20%
20%
20% 2. 50 times per week1. Enter answer text here...2. Enter answer text here...3. Enter answer text here...4. Enter answer text here...
10
(estimated from: Minnesota Department of Health 2013).
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KL2014 28
Which of the following is not a Positive Safety Culture Characteristic
20%
20%
20%
20%
20%1. Mutual Trust2. Confidence in efficacy of preventive
measures3. Punitive action4. Shared perceptions of the importance of
safety
10
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KL2014 29
Which of the following is not a Positive Safety Culture Characteristic
20%
20%
20%
20%
20% 3. Punitive action1. Enter answer text here...2. Enter answer text here...3. Enter answer text here...4. Enter answer text here...
10
HSC (Health And Safety Commission), 1993. Third report: organizing for safety. ACSNI Study Group on Human Factors. HMSO, London.
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KL2014 30
High Reliability Systems…
20%
20%
20%
20%
20% 1. Are less sensitive to operations 2. Lack cultivation of resilience3. Are not willing to organize around expertise 4. Are pre-occupied with Failure5. Enter answer text here...
10
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KL2014 31
High Reliability Systems
20%
20%
20%
20%
20% 4. Are Pre-occupied with Failure1. Enter answer text here...2. Enter answer text here...3. Enter answer text here...4. Enter answer text here...
10
Karl E. Weick & Kathleen M. Sutcliffe, “Managing the Unexpected,”Jossey‐Bass, 2001