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# Statistics 242 Statistical Computing

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Statistics 242 Statistical Computing Instructor: Duncan Temple Lang TA: Gabe Becker 1 sta242 Send general/public mail to Web site 2 sta242 Changing Scheduled Times Do you want some of the meeting time to be a discussion led by the TA - Gabe Becker Can we all make Friday 8.30 - 9.50 Wednesday 11 - 12.50 3 sta242 Simple Guidelines If you don't understand what I am talking about or some particular thing I say, and you have been making the effort to pay attention, then Please, please ASK ME TO EXPLAIN IT DIFFERENTLY
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##### Computer programming

Informations

A24/B24: The Human Factor:
Communication and Teamwork in Health Care
Why is Communication and
Teamwork so critical to the
Healthcare Industry?
Allan Frankel MD
Partners HealthCare System
Michael Leonard MD
Kaiser Permanente
December 2003
Childrens Hospital, Boston
1A24/B24: The Human Factor:
Communication and Teamwork in Health Care
Topics for today
• High Reliability Systems
• Human Cognition
• Complexity and Probability
• Normal deviation of behavior
• Accountability
• Human Factors – Skills for Teamwork and
Communication
High Reliability
• High Reliability Organizations
– Preoccupation with failure/safety
– Reluctance to simplify interpretation
– Sensitivity to operations
– Commitment to resilience
– Deference to expertise
2A24/B24: The Human Factor:
Communication and Teamwork in Health Care
Cognition and Error
• Automatic
• Rule-based thinking
• Knowledge-based thinking
• Slips and Lapses
• Rule based errors
• Knowledge based errors
Complex Systems
• Probability of performing perfectly:
Probability of success, each element:
0.95 0.99 0.999 0.9999
1 0.95 0.99 0.999 0.9999
25 0.28 0.78 0.975 0.997
40 0.12 0.66 0.96 0.995
100 0.006 0.37 0.90 0.99
3
# of stepsA24/B24: The Human Factor:
Communication and Teamwork in Health Care
Rate of Errors
Salvendy
• Errors of omission 1/100
– Forgetting to turn on a pump
• Errors of commission 3/1000
Complex systems
– Misreading a label• Probability of Performing Perfectly:
Probability of success, each element: • Severe stress0.95 0.99 0.999 0.9999
1 0.95 0.99 0.999 0.9999
25 0.28 0.78 0.975 0.997 – 90% error rate
40 0.12 0.66 0.96 0.995
100 0.006 0.37 0.90 0.99
Deviation is Normal and leads to
Systemic Migration of Boundaries. Amalberti
100%
Agreement ‘Illegal normal’
Non- Real Life standards 100%
acceptable
-60 95% Expected safe
space of action BTCU
as defined by
professional
standardsSafety Reg’s &
good practices Usual Space
Of Action
Certification
accreditation
ACCIDENT standards
HIGH Production Performance LOW
Rene Amalberti, MD, PhD
4
# of steps
LOW Individual Benefits HIGH
VERY UNSAFE SPACEA24/B24: The Human Factor:
Communication and Teamwork in Health Care
Systems Design
Example: A Car
• First Production
– The engine for the car
• Then the Quality
– The suspension for the car
• Then the Safety
– Seat Belts and Air Bags
Accountability
5A24/B24: The Human Factor:
Communication and Teamwork in Health Care
Accountability Methods
• Outcome-based
action
• Risk-based
action
• Rule-based
action
Types of Behavior
human
error intentional
violation
unintentional
risk reckless
conduct
Negligence
6A24/B24: The Human Factor:
Communication and Teamwork in Health Care
We know that the healthcare industry
is error prone and is perceived as
unresponsive:
• Blendon NEJM 2002:
• 42% of Americans have had personal experience
with a medical error.
• 38% said system was unresponsive.
• 1/3 of physicians or family personally experienced
medical errors.
• 30% physicians saw an error in the past year
• 60% believe they will see one in the next year.
We have trained physicians to be un-
communicative.
• Wu JAMA 1991.
– 1/3 of residents admitted to making fatal
mistakes but only 50% were disclosed to their
attendings.
– Only 25% were disclosed to the patient.
– 2/3 of physicians didn't feel comfortable
discussing a medical error with a close friend.
7A24/B24: The Human Factor:
Communication and Teamwork in Health Care
We don't teach or incorporate ethical
thinking into practice, nor do we
support open discussion:
• Lehmann 2002: 1/5 of medical schools have no
curriculum on ethics. 40% have no funding for
curricular development on ethics.
• Hicks et al BMJ 2001: 40% of students felt that
they were pressured to frequently or occasionally
act unethically.
• Green Arch Int Med 2000: 14% residents would
fabricate a laboratory value. 5% would lie about
an occult stool test to hide a mistake.
Why Focus on Communication ?
* The overwhelming majority of untoward
events involve communication failure
* Somebody knows there’s a problem but
can’t get everyone in the same movie
* The clinical environment has evolved
beyond the limitations of individual human
performance
8A24/B24: The Human Factor:
Communication and Teamwork in Health Care
Error is Inevitable Because of
Human Limitations
* Limited memory capacity – 5 pieces of
information in short term memory
* Negative effects of stress – error rates
* Tunnel vision
* Negative influence of fatigue and other
physiological factors
* Limited ability to multitask – cell phones and
driving
* Flawed teamwork – Brady bunch or Manson
family ?
JCAHO Sentinel Events
• Communication breakdowns remain the
primary root cause of more than 60% of the
2034 sentinel events analyzed.
• The majority of sentinel events (75%)
resulted in a patient death.
• Suicide (16.1%)
• Operative/postop complications (12.4%)
• Wrong-site surgery (11.8%)
• Medication errors (11.5%)
9A24/B24: The Human Factor:
Communication and Teamwork in Health Care
There are significant discrepancies in
evaluation of teamwork between
physicians and nurses:
• Sexton (publication pending).
• Evaluation of ICU staff in 32 ICU's:
• 50% of RN's rated physicians teamwork skills as
effective while 90% of those physicians rated their
own teamwork skills as effective.
• There is a direct relationship between nursing
retention in these ICU's and the perception of
physician teamwork skills by RN's.
MD –RN: Different
Communication Styles
* Nurses are trained to be narrative and descriptive
* Physicians are trained to be problem solvers “
what do you want me to do” – “ just give me the