Presentation
The Interprofessional Patient Safety Conference: Utilizing Human Factors Engineering and Systems Thinking to Advance Beyond Blame and Shame
DescriptionOver twenty years after the Institute of Medicine’s report on the state of medical errors and emerging from a pandemic, health care still faces many challenges. Health care interprofessionals still need better communication and shared mental models if we are to decrease preventable medical errors. Not only must we teach interprofessional colleagues how to work together but how to think critically together, striving towards continuous improvement. While system error identification and implementation of potential solutions is a fundamental approach for High Reliability Organization training, it is often a struggle to implement given the lack of time in the medical curriculum and if it is taught, professions are often siloed from each other in this learning.
This presentation will introduce an educational model that integrates interprofessional learning from system defects in healthcare delivery, known as the Patient Safety Conference. In contrast to the more traditional Morbidity & Mortality Conference techniques used to examine medical error, this interprofessional conference is a type of error analysis that unites interprofessionals in a detailed discussion about patient care that did not go as planned, including a focus on near misses or events that did not result in harm. The conference design requires that interprofessionals meet and discuss care delivery systems from multiple vantage points. Vulnerabilities in care processes are highlighted with process maps and cause and effect diagrams. High Reliability Organization principles are defined and articulated in alignment with the case. Both the local context, outlining how the institution understands the problem, as well as a broader literature review context, outlining what is collectively known about the problem, are engaged. Finally, proposed action items, or system changes, which may have prevented harm if implemented, are presented for active discussion with the audience. Human Factors Engineering principles are highlighted in a multitude of examples from electronic medical record limitations or interventions to interpersonal team communication techniques.
Audience participation is the final key requirement for the Patient Safety Conference experience. The presenters are coached and therefore expected to serve as facilitators throughout the conference. The result is a conference delivered by a trainee who takes a powerful stage before peers and interprofessional colleagues alike. The conference experience instills the not only the ability, but the expectation for self-reflection in a learning environment, as well as an openness to discuss the vulnerabilities of medical systems and how to prevent them.
This presentation is directed towards physician educators, HFE scientists, and healthcare interprofessional healthcare workers who want to lead medical error discussion and change, either by developing new interprofessional interactive conferences or by optimizing existing academic conferences. The presentation will introduce a roadmap for how to develop an interprofessional discussion-based conference format and identify specific key components for successful implementation. This includes core domains required for an effective and robust discussion such as key requirements of the conference, preparation, and day-of facilitation. It will demonstrate a phased approach to developing each aspect of the conference. Finally, the presentation will highlight the fact that once established, a medical error interprofessional conference is a powerful vehicle to examine patient cases that may run the gamut of systemic challenges we face in daily practice including diagnostic errors, heuristics, and other HFE principles.
This presentation will introduce an educational model that integrates interprofessional learning from system defects in healthcare delivery, known as the Patient Safety Conference. In contrast to the more traditional Morbidity & Mortality Conference techniques used to examine medical error, this interprofessional conference is a type of error analysis that unites interprofessionals in a detailed discussion about patient care that did not go as planned, including a focus on near misses or events that did not result in harm. The conference design requires that interprofessionals meet and discuss care delivery systems from multiple vantage points. Vulnerabilities in care processes are highlighted with process maps and cause and effect diagrams. High Reliability Organization principles are defined and articulated in alignment with the case. Both the local context, outlining how the institution understands the problem, as well as a broader literature review context, outlining what is collectively known about the problem, are engaged. Finally, proposed action items, or system changes, which may have prevented harm if implemented, are presented for active discussion with the audience. Human Factors Engineering principles are highlighted in a multitude of examples from electronic medical record limitations or interventions to interpersonal team communication techniques.
Audience participation is the final key requirement for the Patient Safety Conference experience. The presenters are coached and therefore expected to serve as facilitators throughout the conference. The result is a conference delivered by a trainee who takes a powerful stage before peers and interprofessional colleagues alike. The conference experience instills the not only the ability, but the expectation for self-reflection in a learning environment, as well as an openness to discuss the vulnerabilities of medical systems and how to prevent them.
This presentation is directed towards physician educators, HFE scientists, and healthcare interprofessional healthcare workers who want to lead medical error discussion and change, either by developing new interprofessional interactive conferences or by optimizing existing academic conferences. The presentation will introduce a roadmap for how to develop an interprofessional discussion-based conference format and identify specific key components for successful implementation. This includes core domains required for an effective and robust discussion such as key requirements of the conference, preparation, and day-of facilitation. It will demonstrate a phased approach to developing each aspect of the conference. Finally, the presentation will highlight the fact that once established, a medical error interprofessional conference is a powerful vehicle to examine patient cases that may run the gamut of systemic challenges we face in daily practice including diagnostic errors, heuristics, and other HFE principles.
Event Type
Oral Presentations
TimeTuesday, March 262:37pm - 3:00pm CDT
LocationSalon A-4
Simulation and Education