05/16/2016 by Richard Corder 0 Comments
Black Box Enabled Surgical Suites?
Medical errors are estimated to be the third leading cause of death in America. This is worth repeating – the THIRD leading cause of death in this sophisticated, educated, economic power house of a country is mistakes, errors, mishaps…
Why aren’t we outraged? Why aren’t we paying more attention?
I understand that healthcare, as a "system", is a complicated, ever changing industry that relies on fallible human beings to work well in complex, difficult to repeat situations each and every day. But, here’s the reality – healthcare is NOT alone! There are industries equally as risk-filled with far better safety records! Why is it that the same level of safety we demand for our automobiles or airline travel is not demanded to protect a life, our’s or a loved one’s, when we enter a hospital?
There are many industries, other than healthcare, that work in complex environments where the actions of one human can impact the life of another. Healthcare leaders need to acknowledge the reality that we have much to learn from other industries. While we cannot mimic others entirely, the same general operating principles (including mindfulness that serves as the overarching organizational spirit) that are the foundation for other high reliability organizations (i.e.: aviation, nuclear power) can work just as well to prevent harm from occurring in health systems.
One example of a safe practice or technology that could shared across industries is the in-flight data recorder found on all commercial airliners. It was because of the in-flight data recorder on board the two Boeing 747s that crashed into one another on the island of Tenerife in 1977 that we learned so much about the decisions and behaviors resulting in that game-changing airline disaster. The time stamped voice commands of those at the controls were captured in real-time, and provided a blueprint of what "not to do" along with a snapshot of what needed to be changed.
Now envision this: following a surgical procedure, regardless of the outcome, we have the opportunity to review every piece of data related to the procedure.
We currently have the technology by which we can go back and look at thousands of time stamped data points to review and/or recreate events as they transpired in the operating room. We can capture voice, video, blood pressure, oxygen levels, numbers of plasma/blood transfusions. The data would stream from the medical equipment in the room, from the microphones, the cameras, and any other sources that we choose to capture, into a device that allows playback, review and re-enactment.
We could assess team work, learn from the practice of those at the top of their game, and use this data to improve. We could revisit poor outcomes and learn what should be done differently in similar circumstances. This is not a pipe-dream, nor is it my idea; it has been developed and is currently being used and piloted by Dr. Teodor Grantcharov, a general surgeon at St. Michael’s Hospital in Toronto, Canada.
An innovator if ever there was one.
The choice to innovate is not, in fact, a choice – it’s an imperative.
I firmly believe we have the expertise, the intelligence, the resources, and the creativity to make healthcare less costly, more effective, more patient centered, and far better. We need to give ourselves the permission to try, to innovate, to disrupt our environments in ways that lead to safer, more effective and more humane healing environments.