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

[easyazon_image align="none" height="160" identifier="B0772TJ6V2" locale="US" src="https://emcrit.org/wp-content/uploads/2019/06/51s9KEV2BsL.SL160.jpg" tag="emcrit-20" width="109"]

[easyazon_link identifier="1472439058" locale="US" tag="emcrit-20"]The Field Guide to Understanding 'Human Error'[/easyazon_link]

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:

[easyazon_image align="none" height="160" identifier="1409440605" locale="US" src="https://emcrit.org/wp-content/uploads/2019/06/41UnTiuYgTL.SL160.jpg" tag="emcrit-20" width="105"]

[easyazon_link identifier="1409440605" locale="US" tag="emcrit-20"]Just Culture[/easyazon_link]