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DTSTAMP:20240325T185835Z
LOCATION:Salon A-4
DTSTART;TZID=America/Chicago:20240326T143700
DTEND;TZID=America/Chicago:20240326T150000
UID:HFESHCS_2024 International Symposium on Human Factors and Ergonomics i
 n Health Care_sess139_INDLEC292@linklings.com
SUMMARY:The Interprofessional Patient Safety Conference: Utilizing Human F
 actors Engineering and Systems Thinking to Advance Beyond Blame and Shame
DESCRIPTION:Oral Presentations\n\nMeghan O'Halloran (Edward Hines JR VA Me
 dical Center); Naseema Merchant (West Haven VA, Yale New Haven Health); an
 d Ashley Hughes (College of Medicine, University of Illinois at Chicago)\n
 \nOver twenty years after the Institute of Medicine’s report on the state 
 of medical errors and emerging from a pandemic, health care still faces ma
 ny challenges. Health care interprofessionals still need better communicat
 ion and shared mental models if we are to decrease preventable medical err
 ors. Not only must we teach interprofessional colleagues how to work toget
 her but how to think critically together, striving towards continuous impr
 ovement. While system error identification and implementation of potential
  solutions is a fundamental approach for High Reliability Organization tra
 ining, it is often a struggle to implement given the lack of time in the m
 edical curriculum and if it is taught, professions are often siloed from e
 ach other in this learning. \n\nThis presentation will introduce an educat
 ional model that integrates interprofessional learning from system defects
  in healthcare delivery, known as the Patient Safety Conference. In contra
 st to the more traditional Morbidity & Mortality Conference techniques use
 d to examine medical error, this interprofessional conference is a type of
  error analysis that unites interprofessionals in a detailed discussion ab
 out patient care that did not go as planned, including a focus on near mis
 ses or events that did not result in harm. The conference design requires 
 that interprofessionals meet and discuss care delivery systems from multip
 le 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 t
 he local context, outlining how the institution understands the problem, a
 s well as a broader literature review context, outlining what is collectiv
 ely known about the problem, are engaged. Finally, proposed action items, 
 or system changes, which may have prevented harm if implemented, are prese
 nted for active discussion with the audience. Human Factors Engineering pr
 inciples are highlighted in a multitude of examples from electronic medica
 l record limitations or interventions to interpersonal team communication 
 techniques. \n\nAudience participation is the final key requirement for th
 e Patient Safety Conference experience. The presenters are coached and the
 refore expected to serve as facilitators throughout the conference. The re
 sult is a conference delivered by a trainee who takes a powerful stage bef
 ore peers and interprofessional colleagues alike. The conference experienc
 e instills the not only the ability, but the expectation for self-reflecti
 on in a learning environment, as well as an openness to discuss the vulner
 abilities of medical systems and how to prevent them.   \n\nThis presentat
 ion is directed towards physician educators, HFE scientists, and healthcar
 e interprofessional healthcare workers who want to lead medical error disc
 ussion and change, either by developing new interprofessional interactive 
 conferences or by optimizing existing academic conferences. The presentati
 on will introduce a roadmap for how to develop an interprofessional discus
 sion-based conference format and identify specific key components for succ
 essful implementation. This includes core domains required for an effectiv
 e and robust discussion such as key requirements of the conference, prepar
 ation, and day-of facilitation. It will demonstrate a phased approach to d
 eveloping each aspect of the conference. Finally, the presentation will hi
 ghlight 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 diagnost
 ic errors, heuristics, and other HFE principles.\n\nTrack: Simulation and 
 Education\n\nSession Chairs: Michael Boyce (Yale New Haven Health) and Car
 men Van Ommen (Embry-Riddle Aeronautical University)
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