You Can Either Learn or You Can Blame, You Can't Do Both
Steps Prior to the M&M
Find a Case
The standard referral paths (hospital reporting, pissed off administrators, mortalities) will happen automatically. But you also want to establish yourself as a Master of Whisperers. The way to get people to report cases is to inspire trust. You need to offer protection, establish clear patterns of non-putative motives, and show that you actually do something with the information reported.
Build a Thin Timeline
Comb the chart to build an initial time-line. This will only reflect events, but will offer little actual understanding of what took place.
Interview Primary Decision-Makers
- Dr. Douros asks lets them know he wants to meet over coffee and asks them to write up a 1 paragraph description of events.
- He sends out a Pre-Reading Sheet of what to expect.
- The goal is to find the inflection point where things diverted from optimal care
- Then to get to the point where the actions that occurred make sense
- Seek to Understand Local Rationality
- Knowledge at the time
- Focus at the time
- Goals at the time
- Goals of this interview overlap greatly with the skillset of a simulation debriefer. As such, check out Simulcast for amazing resources.
Build a Thick Timeline
Incorporate the results of the interview(s) into the timeline
Remember, ED cases are not contiguous they are stimulus/response based
Analyze for Systemic Problems and Brainstorm Solutions
Behavior must be judged as if the outcome is not known. If it was ok when things go right, it is ok when things go wrong.
Presenting the M&M
Dr. Douros does 2 cases in a one-hour block, 1 of them an M&M and the other a Safety & Success case (similar to the Amazing & Awesome Rounds).
Remind the group that this is about learning and identifying systemic problems, not about blame & shame.
Present the Thin and Thick Timelines
- Should take about 10 minutes.
- Exclude extraneous information
- The case can be presented by a Junior, but there needs to be a master facilitator at all sessions
Discuss the Case
Probe for Systemic Problems and Solutions
Send F/U Email with Lessons
To reinforce for those who attended and fill in those who did not
Recommended ResourcesThe Field Guide to Understanding ‘Human Error'
This is the first go-to, a must read. It will change your vision of error.
Next, you can move on to another Dekker book:Just Culture
- Ten Principles White Paper
- An example of an amazing deep dive on equipment failure
- How Complex Systems Fail
More from George
Work-To-Rule Strike (malicious compliance)
Now on to the Podcast…
- EMCrit 290 – Decompensated Hypothyroidism and Myxedema with Dr. Arti Bhan - January 23, 2021
- EMCrit 289 – Ketamine Only Intubation Paper with Brian Driver - January 12, 2021
- EMCrit 288 – Neurogenic Shock & Should we be Using Vasopressors for Hemorrhagic Shock? - December 29, 2020