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Health 2.0 SoftServe Session: Similairty between an oil rig & hospital

As an industry, health care is trying to reinvent itself with significant fuel from its' consumers, but the reality is that we can learn from other more advanced industries. Originally presented by the Dutch Center for Patient Safety (iPatientSafety) at a recent Health 2.0 Amsterdam event, this topic will explore the similarity between a very conservative, but very advanced industry, and the hospital setting. One key lesson that will be explored is the insidiousness of human error and how we can overcome this by engaging key stakeholders with a human being at the center.

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Health 2.0 SoftServe Session: Similairty between an oil rig & hospital

  1. 1. WHAT IS THE SIMILARITY BETWEEN A HOSPITAL & AN OIL RIG? Eugene Borukhovich, @HealthEugene VP Healthcare, European Markets
  2. 2. Important Message Serge Diekstra major hazard risk analyst Gert-Jan Kamps junior risk analyst Dutch Center for Patient Safety in Leiden -Naturalistic approach -Focus on “how people are using technology?” instead of “how people should use technology?”
  3. 3. “What is the most expensive accident in oil & gas history?” 3
  4. 4. BP DEEPWATER HORIZON - GULF OF MEXICO What can you remember?
  5. 5. BP Deepwater Horizon Disaster  On the evening of April 20th 2010, an explosion occurs on a drilling platform, ~50 miles off the coast of Louisiana  A crew of 126 people: 11 deaths  Extent of the pollution: ~5 million barrels of oil (~800 million liters)  Surface area of the oil spill: >175.000 square miles
  6. 6. 2 months later: BP market cap loss $100+ billion
  7. 7. DWHI Accident Investigation ?
  8. 8. DWHI Accident Investigation Report
  9. 9. Who or what is to blame?
  10. 10. Joel Achenbach: Systematic accidents “No one saw it coming. They were doing routine things with no sense of impending calamity. They didn’t hear the ticking of the time bomb. The first warning, for many, was the shaking, the trembling, the deep and powerful vibration that gripped the massive rig. The Deepwater Horizon shuddered to its bones.” 16
  11. 11. 17 Joel Achenbach: Systematic accidents “You could think of it as dominoes falling, except it’s more brutal than that: The dominoes are all simultaneously crushed from above.”
  12. 12. Joel Achenbach & Perrow: It gets worse  The rig had thousands of years of drilling experience on board, but no one had ever been through anything like this.  Many holes were poked into the system by many participants, but no one owned the overview - the entirety of the risk.  Maybe most shocking of all: no one on the Deepwater Horizon was aware of the impending disaster they had unleashed.
  13. 13. “How does all this relate to health 19 care?”
  14. 14. John T. James - Preventable harm in healthcare  Annually, 210.000 - 440.000 fatalities from preventable error in US Healthcare alone.  Not included in this figure for the most part: errors of omission.
  15. 15. “So what is the thread that runs through oil & gas and healthcare?”
  16. 16. One of the answers: the insidiousness of human error
  17. 17. Systematic organizational risk: predictable formula for disaster Overconfidence bias Anchoring bias Confirmation bias Time bias
  18. 18. James Reason: Human Error & Swiss Cheese Model  ‘”Human error is a consequence not a cause.”  “We cannot change the human condition, but we can change the conditions under which humans work”
  19. 19. Thank you! 25