You Can Either Learn or You Can Blame, You Can't Do Both
–Sydney Dekker
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).
PreBrief
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
~10-15 minutes
Probe for Systemic Problems and Solutions
~10-15 minutes
Send F/U Email with Lessons
To reinforce for those who attended and fill in those who did not
Recommended Resources
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:
- Ten Principles White Paper
- An example of an amazing deep dive on equipment failure
- How Complex Systems Fail
More from George
Additional Links
- Work-To-Rule Strike (malicious compliance)
- Learning from Excellence Project
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Fascinating discussion, thanks. Despite the lip service, we still have a long way to go creating a hospital culture in which people are not scared to discuss their decision making openly without fear of judgement. In the podcast, Scott brings up the point that someone’s decision resulting in a bad outcome is scrutinized, while the same decision or behavior in a different case that happens to result in a good outcome is given a free pass. Obviously, this is a result of cognitive bias, but how to combat it? One way would be to include in the discussion 10 situations… Read more »
Great podcast, Dr Douros “gets it”. The culture of blame is the antithesis of patient safety and process improvement since it takes the easy way out. Real improvements in patient care requires a culture of reporting, which in turn requires trust from everyone in the organization. To that end our multi-specialty practice in Colorado has partnered with our liability carrier to encourage reporting of unexpected outcomes. Our liability carrier gets more real time notification of potential high risk cases and we analyze the cases (a la Dr. Douros) under their peer review umbrella. This process allows us to avoid punishing… Read more »
This is a great discussion and topic. I just started reading the first recommended book by Sidney Dekker. Have you come across any recent criticisms of the new view of human error? This seems like a very contrasting view and just wanted to know if there is any evidence against this view. Thanks for the great podcast!
Very important topic. We have also struggled with ineffective M&M rounds a number of years ago; here is our journey on revamping the process, and incorporating patient safety and quality concepts to build an easy-to-follow framework for all medical groups to use:
https://emottawablog.com/2018/03/improving-morbidity-mortality-rounds-om3/
This OM3 has been implemented now at many centres across Canada and internationally with great feedback. Check it out!
Great podcast, and thank you for the additional resources. I note that the “Work-To-Rule Strike (malicious compliance)” link is not active. Having just punched the term into a search engine, I’m very keen to be guided towards a good resource to delve further into this topic (beyond W****edia). Cheers!
[…] Duoros presents a series of questions on the EMCrit Podcast to guide the collection of this human factors […]