Tag: quality improvement

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Anesthesia Education Anesthesia Equipment and Technology Clinical Tips Leadership in Emergencies Preparing for Grad School/Residency

#97 – Safety is a capacity

What up folks! This is another short podcast on the idea that safety is a capacity, not an outcome. This idea comes out of Todd Conklin & Sidney Dekker’s work on organizational safety where they discuss two ways of looking at safety:

The Safety 1 Perspective or the old way of thinking is that safety is about minimizing errors.  It’s about identifying risks, including human behaviors, and implementing steps to prevent errors from happening.  Success is often measured in low to zero error rates and errors are punishable offenses.  

The Safety 2 Perspective doesn’t overlook the need to minimize errors.  But it focuses on building the capacity for the right thing to happen versus a feverish focus on whack-a-moling potential risk and, frankly, whack-a-moling the people who make mistakes.

The idea is that safety is not an outcome but rather a capacity that’s built up over time through thoughtful design of systems and careful handling of people and systems both when things go right as well as when errors happen.  It’s about figuring out how humans are doing the work – including all of their workarounds – in order to generate successful outcomes and finding ways to support and foster positive outcomes on a consistent basis.  And when things go wrong, people aren’t punished.  While egregious error or outright negligence is always possible, Safety 2 presumes people are smart and are trying to do the right thing.  So if something goes wrong, there is likely a system input, factor or design that created a high probability that something would in fact go wrong.  So the focus is on understanding how the worker performed in a faulty system and trying to improve that system so there’s a higher likelihood that the right thing happens the next time around.

Check out the short podcast for a couple of illuminating stories to bring these principles to life. As always, drop me an email or message on social media if you’d like to connect!

Resources:

Todd Conklin’s Pre-Accident Investigation podcast

Sidney Dekker’s professional website

Upcoming conferences I’m speaking at:

Maine Association of Nurse Anesthesiology: https://meana.org MEANA Fall Conference in Portland, Maine (virtual option available)

Encore Symposium’s New England at the Cliff House, Cape Neddick, Maine October 16-19, 2023

Encore Symposium’s Autumn in Bar Harbor & Acadia National Park, October 14-17, 2024

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Anesthesia Education Business/Finances Clinical Tips Preparing for Grad School/Residency

#83 – Positive Deviance as a Catalyst for Change with Cherie Burke, DNP, CRNA

“Positive deviance is really about… taking those things that people are doing right and sharing them with everyone so that everyone is doing things to improve our patients’ care, our patients’ outcomes.” 

Cherie Burke, DNP, CRNA

Dr Cherie Burke joins me to unpack how positive deviance can be a catalyst for change in healthcare.

Positive deviance is all about looking for what’s going right and transferring those lessons to other opportunities, processes & providers to improve performance.

Aggressive action & investigation is the norm when something goes wrong. Think about when a sentinel event happens. There’s mandatory reporting, root cause analysis (RCAs), critical incident debriefs and a concerted effort to prevent errors & improve processes in the future. Positive deviance is a process of applying a similar degree of effort to what’s working right. Can we find the high performers, figure out what they’re doing well and transfer those techniques, processes & beliefs to other domains?

Cherie Burke, DNP, CRNA completed her Master of Science in Nursing at DeSales (duh-sales) University, her Doctorate in Nursing Practice at La Salle (la-sal) University, a post-doctoral fellowship in patient safety at the VA Medical Center in Philadelphia and is currently a PhD candidate at Duquesne (do-cane) University.

Dr Burke and I worked together at Maine Medical Center in Portland, Maine and have also taught alongside one another with Cornerstone Anesthesia Conferences. Cherie is actually who connected me with Jayme Rueter, the CRNA who founded Cornerstone and who gave me my first shot at teaching other CRNAs at continuing education conferences.

I think you’re going to enjoy this conversation… learning how to find positive deviance at play in our organizations is key for us to improve the work that we do.

This episode was originally released on From the Head of the Bed on January 26, 2016.

Resources: 

Bradley, E. H., Curry, L. A., Ramanadhan, S., Rowe, L., Nembhard, I. M., & Krumholz, H. M. (2009). Research in action: using positive deviance to improve quality of health care. Implementation science, 4(1), 1-11.

Ford, K. (2013). Survey of syringe and needle safety among student registered nurse anesthetists: are we making any progress?. AANA journal, 81(1).

Gary, J. C. (2013). Exploring the concept and use of positive deviance in nursing. AJN The American Journal of Nursing, 113(8), 26-34.

Lawton, R., Taylor, N., Clay-Williams, R., & Braithwaite, J. (2014). Positive deviance: a different approach to achieving patient safety. BMJ quality & safety, 23(11), 880-883.

Prielipp, R. C., Magro, M., Morell, R. C., & Brull, S. J. (2010). The normalization of deviance: do we (un) knowingly accept doing the wrong thing?. Anesthesia & Analgesia, 110(5), 1499-1502.

Rosenberg, T. (2013, February 27).  When deviants do good.  The New York Times, Retrieved from http://opinionator.blogs.nytimes.com/2013/02/27/when-deviants-do-good/?_r=0

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Clinical Tips Enhanced Recovery After Surgery

#25 – Preventing Hypothermia in Arthroplasty Surgery with Brian McGrory, MD

My guest today is Dr Brian McGrory.  His is an orthopedic joint replacement surgeon at Maine Medical Center in Portland, Maine.   

He earned his bachelor’s degree in chemistry biology at Cornell, attended medical school at Columbia, followed by residency in orthopedic surgery at the Mayo Clinic Graduate School where he also earned a Master’s degree in orthopedic research.  Dr McGrory then completed a fellowship through Harvard University at Massachusetts General Hospital in adult hip & knee reconstruction.  He has served as the research director for orthopedics at Maine Medical Center and the founding editor-in-chief of Arthroplasty Today, which is a publication of the American Association of Hip and Knee Surgeons.

Today we’re going to talk about preventing hypothermia during total joint replacement surgery.  Dr McGrory recently conducted a pilot study at Maine Medical Center evaluating perioperative body temperature in patients undergoing total joint surgery.  All patients in the study received pre-operative warming at 41-degrees Celcius with 3M’s Bair Hugger forced air warmer and intraoperatively they received warm cotton blankets out of common blanket warmers and in-line IV fluid warming with 3M’s Ranger fluid warming device.  The patients in the study group were also draped in a reflective space blanket as the independent variable.  Dr McGrory will discuss the results of this pilot study in the podcast, some of which were published as a letter to the editor in The Journal of Arthroplasty, which I’ve linked to in the show notes. 

And just to review:  perioperative hypothermia has been linked to numerous bad outcomes for patients including increased infection, delayed recovery, increased blood loss, disruptions in coagulation and cardiac events, not to mention, being cold is uncomfortable for the patient.  Perioperative temperature regulation is also linked to Medicare reimbursement with the goal of one temperature reading of at least 35.5C within 30 minutes immediately before or 15 minutes after the anesthesia stop time.  If hospitals meet this mark, they may see a slight increase in reimbursement and if they miss this mark, they may miss out on a substantial percentage of reimbursement.  So there is significant precedence for maintain perioperative normothermia. 

During the podcast, we’re going to hint at the controversy with forced hot air warmers that’s been widely discussed in peer reviewed, as well as popular news, publications.  I want to roll through the conversation with Brian uninterrupted so you can hear how one surgeon has approached that controversy and still achieved normothermia for his patients intraoperatively, but at the end of the show, I’ll unpack & clarify the backstory on Bair Huggers so you know where that stands.  It’s a crazy story that twists through legal battles, medical literature, FDA statements and popular news media… so stay tuned to the end.

References

Carlson, J. (2018 December 8). Legal war engulfs 3M device.  StarTribune.  Retrieved from https://www.startribune.com/legal-war-engulfs-mmm-operating-room-device/502063131/?refresh=true. 

Carlson, J. (2018 December 9). A closer look at the scientific evidence for and against 3M’s Bair Hugger.  StarTribune.  Retrieved from  https://www.startribune.com/a-closer-look-at-the-scientific-evidence-for-and-against-the-bair-hugger/502204321/ 

Carlson, J. (2019 August 1). Judge tosses lawsuits from 5,000-plus plaintiffs against 3M warming blanket. StarTribune.   Retrieved from https://www.startribune.com/judge-tosses-lawsuits-from-5-000-plus-plaintiffs-against-3m-warming-blanket/513491312/. 

Kellam, M. D., Dieckmann, L. S., & Austin, P. N. (2013). Forced‐air warming devices and the risk of surgical site infections. AORN journal, 98(4), 353-369. Retrieved from https://aornjournal.onlinelibrary.wiley.com/doi/epdf/10.1016/j.aorn.2013.08.001 

Madrid, E., Urrutia, G., i Figuls, M. R., Pardo‐Hernandez, H., Campos, J. M., Paniagua, P., … & Alonso‐Coello, P. (2016). Active body surface warming systems for preventing complications caused by inadvertent perioperative hypothermia in adults. Cochrane Database of Systematic Reviews, (4). https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009016.pub2/epdf/full 

Maisel, W., (2017 August 30).  Information about the Use of Forced Air Thermal Regulating Systems – Letter to Health Care Providers. U.S. Food & Drug Administration. https://www.fda.gov/medical-devices/letters-health-care-providers/information-about-use-forced-air-thermal-regulating-systems-letter-health-care-providers

McGrory, B. (2018). Letter to the Editor on “Hypothermia in Total Joint Arthroplasty: A Wake-Up Call.” The Journal of Arthroplasty 33(4) 3056-3059.  Retrieved from: https://www.arthroplastyjournal.org/action/showPdf?pii=S0883-5403%2818%2930506-0 

Meier, B. (2010 December 24).  Doctor Says a Device He Invented Poses Risks. The New York Times. Retrieved from https://www.nytimes.com/2010/12/25/business/25invent.html 

Ralte, P., Mateu-Torres, F., Winton, J., Bardsley, J., Smith, M., Kent, M., … & Guisasola, I. (2020). Prevention of perioperative hypothermia: a prospective, randomized, controlled trial of Bair Hugger versus Inditherm in patients undergoing elective arthroscopic shoulder surgery. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 36(2), 347-352. Retrieved from https://doi.org/10.1016/j.arthro.2019.08.015 

Simpson, J. B., Thomas, V. S., Ismaily, S. K., Muradov, P. I., Noble, P. C., & Incavo, S. J. (2018). Hypothermia in total joint arthroplasty: a wake-up call. The Journal of arthroplasty, 33(4), 1012-1018. Retrieved from https://www.arthroplastyjournal.org/article/S0883-5403(17)30969-5/fulltext 

Turner, T. (2021 March 11). Bair Hugger Warming Blankets. Drugwatch. 

Uggen, C. (2020).  Editorial Commentary: Just Getting Warmed Up: Risks, Benefits, and Economics of Active Warming Devices. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 36(2) Retrieved from https://www.arthroscopyjournal.org/action/showPdf?pii=S0749-8063%2819%2930843-6  

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