This seminar offers a systematic way to learn the science of safe care, how to do the right things at right time, where to use safeguards, and how to identify the combination of root causes that result in an adverse event. The current method of root cause analysis which assumes a single event can cause an adverse event, which according to Dr. Chassin is a misnomer; because there is never a single cause in an adverse event. He sums the argument candidly. “The analytic methods we have are from a different generation. We need to develop the next generation of those tools to achieve the goal of high reliability.” We need a paradigm shift. We need it in a hurry! You cannot cross the sea merely by standing and staring at the water. Do not be afraid to take a big step if one is indicated. No noble thing can be done without risks.
This seminar is about the lessons learned from the presenter’s experience of over 30 years on safety in medical devices, aerospace, healthcare, nuclear power, consumer products, and pharmaceuticals. If healthcare can adopt translocation of such practices, it can fulfill the dreams of the patients in which nothing bad happens to them! This is precisely the aim of this seminar. Safe hospital care is neither a science nor an art. It is a practice just like the practice by a doctor who combines hindsight of experience and foresight of imagination to come up with an outsight of the best interventions and best protocols. Over time the doctor standardizes the process but is vigilant to any unique approach in patient safety is called hazard analysis and mitigation process and is covered in this teaching. It goes a big step farther. It covers innovation strategies to assure that the safety improvements result in high value to the hospital, the patients, and other stakeholders.
Inadequate systems, not inadequate people, usually cause accidents. People are only an element in a system, which can be defined as an integration of interfacing and interdependent entities working together to accomplish a mission. It includes facility, environment, all hospital staff, and services, including support personnel, suppliers, patients, families, and equipment. Human errors are bound to happen in a system of many micro-systems, such as a hospital. The physician treats from a list of differential diagnoses. This is the nature of the treatment process where there are conflicting symptoms, multiple symptoms, false positive and false negative test results, constant distractions, and insufficient information on the patient history. Even the most conscious safety professionals make mistakes. But this does not mean that errors can be ignored. They must be minimized through robust system designs and individual accountability, including the accountability of senior management in developing and monitoring an aggressive Quality Policy.
Even though some progress has been made over the last decade, hospital care still needs a very significant amount of transformation, especially because more patients die from hospital mistakes every year for the last 20 years. Currently, the estimate is about 440,000 deaths per year!
Areas Covered in the Session:-
Background:-
Dr. Lucian Leape, the co-founder of the patient safety movement more than a decade ago is confident that health care is moving in the right direction but the progress to date is dismal. Dr. Mark Chassin, President of the Joint Commission has similar views. “The problem is that we need to generate new knowledge. We have imperfect tools to assess exactly what happened in the course of an adverse event. Then, once we understand where the weak defenses are, we have imperfect analytic tools to tell us which one to fix first.”
Level (Basic/Intermediate/Advanced):-
All levels including senior management.
Why Should You Attend?
The purpose of this seminar is to precisely address the above issues with the use of evidence-based safety theories and tools used in other ultrahigh safety industries such as aerospace, nuclear, and chemical industry. The author with his engineering background as a consultant and medical writer is able to blend the state-of-the-art into patient safety with high return on investment. The return on investment is at least 1000% in most cases.
Who Will Benefit?
Target Companies:-
All hospitals such as Johns Hopkins, Mayo Clinic, and Seattle Children’s Hospital Major equipment suppliers such as GE Healthcare, Medtronic, Johnson & Johnson, and Zimmer Holdings.
Target Association/Societies:-
