The trouble with M & Ms

LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog The widespread acceptance of cognitive bias theory, self-reflection and mindful practice can, in the absence of an equal weighting in systems-thinking training, lead to the notion that most errors are the result of individual failings. This self-recrimination can be compounded by ‘traditionally’ run M&Ms. How do we move away from the old “name/blame/shame/train” cycle of M&Ms? Smarter people than me out of Canada and Sydney have been thinking about this and agree on most of the following. The facilitator A comparison to simulation is pertinent here – anyone can do it, but without training there’s a good chance you aren’t going to do it that well and you might even damage those involved. There is a world of incident investigation and patient safety literature that medical school and specialist training just doesn’t teach. Your state’s department of health will have free formal incident training days (why use the best techniques on the disasters that have already happened and not the near misses?) and there are also patient safety clinical lead courses. Case selection In conjunction with your Quality director review the following for potential cases deaths serious adverse events state-wide Incident Management System reports (related to clinical incidents) complaints cases requiring open dis...
Source: Life in the Fast Lane - Category: Emergency Medicine Authors: Tags: Administration Emergency Medicine error george douros improvement M&Ms Source Type: blogs