7. We nemen het anderen meer kwalijk dat ze onze fouten kennen, dan
onszelf dat wij daaraan mank gaan.
!
Multatuli
!
!
We hold it more against others to know our
failures, than to hold our failures against
ourselves!
!
Multatuli (Dutch writer)!
8.
9.
10. Surgery is responsible for 60% of all Avoidable Errors (22.500)
Direct costs are > 125M euro per year
1,6%
2004
2008
2012
1,2%
0,8%
0,4%
0,0%
Diagnose
Surgical
Treatment Medication
Care
Release
Others
Monitor Zorggerelateerde Schade 2008, NIVEL
11. Systemic learning
I am always ready to learn
although I do not always like
to be taught
!
Winston Churchill
12.
13.
14. KLM (RADIO) Ah roger, sir, we are cleared to the Papa Beacon flight level nine
zero until intercepting the three two five. We are now at take-off
…
TENERIFE TOWER OK....[static noise]
... (KLM initiates take-off)
TENERIFE TOWER Ah, papa alpha one seven three six report the runway clear.
PAN AM (RADIO) OK, will report when we're clear.
...
KLM FLT ENGR (CVR) [Is he not clear, that Pan American?]
KLM CAPTAIN (CVR) [Oh yes. - emphatic]
[Pan Am captain sees landing lights of KLM Boeing at approx. 700 m]
PAN AM CAPTAIN There he is ... look at him. Goddamn that son-of-a-bitch is
coming!
http://planecrashinfo.com/cvr770327.htm
15. KLM (RADIO) Ah roger, sir, we are cleared to the Papa Beacon flight level nine
zero until intercepting the three two five. We are now at take-off
…
TENERIFE TOWER OK....Stand by for take-off, I will call you.!
... (KLM initiates take-off)
TENERIFE TOWER Ah, papa alpha one seven three six report the runway clear.
PAN AM (RADIO) OK, will report when we're clear.
...
KLM FLT ENGR (CVR) [Is he not clear, that Pan American?]
KLM CAPTAIN (CVR) [Oh yes. - emphatic]
[Pan Am captain sees landing lights of KLM Boeing at approx. 700 m]
PAN AM CAPTAIN There he is ... look at him. Goddamn that son-of-a-bitch is
coming!
16. Lesson Tenerife
PLANE1234: [call sign] ready for departure at Runway three zero!
!
TOWER: [call sign], you are cleared for take off Runway three zero!
!
PLANE5678: [call sign] Runway vacated
21. Failures due to communication errors (60 out of 258)
Not Transmitted 49%
Misunderstanding 44%
Not Received 7%
Patterns of Communication Breakdowns Resulting in Injury to Surgical Patients, Greenberg, 2007
25. High reliability organisations
Preoccupation with failure!
•
Anticipation
•
–
Challenge beliefs, don’t stop asking why
?
?
?
Sensitivity to operations!
•
•
Contaiment
Actively find failures and learn
Reluctance to simplify!
•
Succes
Failure
Grasp context and flow
Commitment to resilience!
•
•
Discipline, know what is important
Deference to expertise!
•
–
Open channels
http://www.beckershospitalreview.com/hospital-management-administration/5-traits-of-high-reliability-organizations-how-tohardwire-each-in-your-organization.html?goback=%2Egde_4877284_member_240196966
27. We nemen het anderen meer kwalijk dat ze onze fouten kennen, dan
onszelf dat wij daaraan mank gaan.
!
Multatuli
!
!
We hold it more against others to know our
failures, than to hold our failures against
ourselves!
!
Multatuli (Dutch writer)!
31. Core issues implementation in hospital
Independent and safe!
• No connection to EPD
• No data to IGZ
• Secure storage
• Only used for independent research
• Integrated and objective!
• Indisputable data
• Integration of data streams in the timeline
• Only to be used for organisational learning!
• No Blame
• No obsolete data
•
