Avatars – individuals playing the game
– can create their own Avatar, clothes, appearance, name etc & can change & update
– forums for discussion
– Points for information revealed & big points if changes made
– League tables – by region, state, country, world
– Highest climber, highest newcomer
– Project creator – have come up with new projects
– (Could list each project Avatar involved in driving?)
– Eg ‘Champions’ – have been involved in a team which has seen a project to fruition
– can take photos of hazard (eg filter with untethetered cap) – ???GPS linking ensures it’s at that hospital
– (Coming out parties for those who feel comfortable to reveal their identity)
Hooks
– make it fun
– regular update messages – new hospitals entering, where own hospitals are in ranking, new games created
– any individual can play the more who register for a particular hospital the more fractions of a point that hospital receives – fraction can relate to size of hospital by eg staff numbers (one player can register for one hospital once yet can register for several hospitals). (Players who enter incorrect info on purpose can be locked out if it doesn’t agree with majority info)
– forum – chat with others about how got hospitals to change. Messages when hospital has made a change which your hospital needs to make & how it was done.
– Presentation links to give to hospitals about need for change for particular item
– The earlier you get in the higher you’ll be on the leader board compared to place with similar score (still registered as eg equal first if same score as first place but on leader board name will appear earlier)
– reverse exponential release of rewards ie lots initially when start playing then less and less frequent (eg time between new challenges could gradually be longer and longer – known as variable ratio schedule of reinforcement) also vary the length of any one game session – forces you to wait before jumping in again
– Make them super quick, easy to get in to and learn, incredibly fun and rewarding sound and graphical design
– honourable mentions, honours list, extra scores for engagement & involvement with human factors discussions & developing new projects,
– Include forums for people to tell de-identified stories and suggest improvements in hospital environments
– Label ‘patient safety game master’ eg those who have identified a new hazard or part of a group which has seen a project to fruition
– Avatars could have details attached to them – what hazards identified, groups in, scores, history, background
– Simple to use using all forms of media – Facebook, twitter, email etc
– Front end looks extremely appealing
– Simple to navigate with minimal clicks to further info
– People entering data feel secure (don’t need to provide their details – could be made up info yet anyone within that hospital can verify the info and change)
– ?Can see how many & which avatars logged in & playing so can converse with them?
Rough Notes:
The Patient Safe Game
Welcome to the PatientSafe Game https://www.psnetwork.org/the-patientsafe-game/
Our goal is to ensure all patients are looked after in the best possible environment.
The rules are simple
Front line staff (as avatars) provide information about their work environments and what could be improved.
Specific focus will be on ‘sub games’ which look at the equipment and systems staff are interacting with
The sub games may for example may focus on a specific pieces of equipment eg oxygen cylinders (see https://www.psnetwork.org/oxygen-cylinders-deadly-by-design/)
These pieces of equipment have been provided with a score dependent on their usability. (Similar to energy ratings of fridges). (This score has been generated transparently by human factors experts working in collaboration with front line staff and others and is available for review and comment as per eg Which/Choice magazine)
The overall scores for each hospital will be tallied. Influential staff (CEO, procurement heads, departmental heads) from each hospital will be provided with feedback on how they have performed and what they might do to improve.
Note that hospitals/trusts (in the U.K.) have displayed an acceptance of being prepared to be placed in league tables based on performance criteria as assessed by front line staff https://www.gov.uk/government/publications/learning-from-mistakes-league
Note that front line staff also have displayed a willingness to provide information regarding equipment and systems specific to their institution – data for the ‘Crash Call Number’ standardisation in Australia has been crowd sourced via social media: https://www.psnetwork.org/australian-crash-call-number-standardisation/
Front line staff willingness to provide data may increase through
– review of implications of Code of Conduct
– review of implications of (standard) Contract agreements with employing hospitals
– official appearance & support of PatientSafe Game by higher authorities
– safety in numbers (knowledge that others are doing it without any negative repercussions)
– endorsement by senior bodies (NHS etc, Ramsay)
Rough Notes
This post discusses how assessment and refinement of medical devices can be greatly improved https://twitter.com/terryfairbanks/status/971569490248065026?s=21
All hospitals are involved. Information can be provided by anyone – patient to hospital CEO)
Scoring system example:
3 points for doing the right thing (can whatever scoring scale we choose dependent on the game)
1 point if doing the wrong thing (bad news demonstrates there’s a willingness to change & improve)
0 points if not taking part in a particular challenge
Challenges are set by an independent collaborative group of healthcare staff and system safety experts. (Using BaseCamp group already set up which can increase in size as needed – already has several front line healthcare staff and human factors experts within it)
We will keep a list of the challenges (click on each to read more including presentations) and how each hospital is faring. If you would like to discuss a challenge further then please do get in touch.
Joe Kiani, others – fund
Whiteboard.is, others – software creation
Ant – video explanation
Rhys – look at
Jo/Silas – ?pilot in Ramsay
Umesh – watch & advise
Eric – Whiteboard.is
Todd – watch & advise
Steven Shorrock – human factors lead
Martin Bromiley – human factors lead
Beth & Courtney – front line change Nurses
Brad – obtain emails
(Dr Murphy – obtain info on existing scoring systems eg NHS). Note that front line staff have already demonstrated a willingness to provide information about their work environments through social media – Crash Call Numbers in Oz – https://www.psnetwork.org/australian-crash-call-number-standardisation/
Game could auto-generate a generic email to be copied and forwarded from (anonymous/game itself) to send to influencers in the hospital with links to things that can be upgraded to improve safety within that institution.
We could start an extremely rough version of the game now if we decide upon a scoring system for the starter games – who wants to play?
I’m going to start and will post an excel file into the docs&files section scoring each of the hospitals I work based on the starter games.
From there we could work with Whiteboard.is to develop prototypes and test them amongst ourselves within the hospitals we work in already.
Generate list of emails of CEOs, MAC committee members, theatre NUMs.
(speak to Brad)
Generic email sent from psnetwork.org account
Congratulations
St elsewhere has been registered as the X safest hospital in the world
Subgames = Projects each with a team and team leader(s) who are interconnected with everyone else. They focus on that particular equipment or system type with input from throughout the network.
Starter games (games to put in from the start)
Chlorhexidine – https://wp.me/p8r3e4-x6
Filters – https://www.psnetwork.org/police-investigate-blocked-anaesthetic-breathing-circuits/
Valved IV fluid bags – https://wp.me/p8r3e4-5q
Paracetamol bags not vials – https://wp.me/p8r3e4-7O
BVM with expiratory valve – https://wp.me/p8r3e4-mX
Between the flags – https://www.psnetwork.org/burning-dental-drills/
Mobile phone reception – https://www.psnetwork.org/mobile-phone-reception-survey/
Enteral feeding tubes – https://wp.me/p8r3e4-6n
Other games (perhaps further input required from BaseCamp prior to using)
Standardise Crash Call Phone Number – https://www.psnetwork.org/standardise-the-crash-call-telephone-number/
Oxygen Cylinders – https://www.psnetwork.org/oxygen-cylinders-deadly-by-design/
Automated bar code cold chain blood storage
Cannula replacement as required – https://www.psnetwork.org/stop-routine-cannula-replacement/
Draeger APL – https://www.psnetwork.org/tga-replace-all-old-draeger-apl-valves-in-australia/
Capnography monitoring at all intubation locations
VLDL available for all intubations – https://www.psnetwork.org/video-direct-laryngoscopy-2/
Sugammadex availability – https://www.psnetwork.org/sugammadex/
Muscle relaxants with red tops & paralysing agent written on lid
In hospital App for all speedy contacts
User friendly defibrillators – (Ken Spearpoint & Terry Fairbanks)
Neuraxial connectors ISO standard
#endPJparalysis – https://m.youtube.com/watch?v=2Bkctvi5UoI&feature=youtu.be
Later
Plain Language alerts (as opposed to confusing colour codes) – https://wp.me/p8r3e4-yq
Minimise caps & bungs etc
One way valves in IV sets
Name & Role policy – #HelloMyNameIs & #TheatreCapChallenge
Central lines bonded caps – https://www.psnetwork.org/central-line-related-air-emboli-at-least-1-avoidable-death-every-day/
Central line dressings ‘remove supine’ – https://www.psnetwork.org/central-line-related-air-emboli-at-least-1-avoidable-death-every-day/
‘Remove Central Lines Supine’ animation – https://www.psnetwork.org/remove-central-lines-supine-2/
ETO2 monitoring at all intubation locations – https://www.psnetwork.org/oxygen-analysers/
Other standardised drug ampoules appearance
Rate your EHR
ORBlackBox
MRI safety standards
Avatars – individuals playing the game
– can create their own Avatar, clothes, appearance, name etc & can change & update
– forums for discussion
– Points for information revealed & big points if changes made
– League tables – by region, state, country, world
– Highest climber, highest newcomer
– Project creator – have come up with new projects
– (Could list each project Avatar involved in driving?)
– Eg ‘Champions’ – have been involved in a team which has seen a project to fruition
– can take photos of hazard (eg filter with untethetered cap) – ???GPS linking ensures it’s at that hospital
– (Coming out parties for those who feel comfortable to reveal their identity)
Hospital/Day Surgery
– league tables again by region, state, country, hospital or day surgery
– Highest climber (most improved)
– Highest New comer
– ?’Champions’ – on full marks at some point
Hooks
– make it fun
– regular update messages – new hospitals entering, where own hospitals are in ranking, new games created
– any individual can play the more who register for a particular hospital the more fractions of a point that hospital receives – fraction can relate to size of hospital by eg staff numbers (one player can register for one hospital once yet can register for several hospitals). (Players who enter incorrect info on purpose can be locked out if it doesn’t agree with majority info)
– forum – chat with others about how got hospitals to change. Messages when hospital has made a change which your hospital needs to make & how it was done.
– Presentation links to give to hospitals about need for change for particular item
– The earlier you get in the higher you’ll be on the leader board compared to place with similar score (still registered as eg equal first if same score as first place but on leader board name will appear earlier)
– reverse exponential release of rewards ie lots initially when start playing then less and less frequent (eg time between new challenges could gradually be longer and longer – known as variable ratio schedule of reinforcement) also vary the length of any one game session – forces you to wait before jumping in again
– Make them super quick, easy to get in to and learn, incredibly fun and rewarding sound and graphical design
– honourable mentions, honours list, extra scores for engagement & involvement with human factors discussions & developing new projects,
– Include forums for people to tell de-identified stories and suggest improvements in hospital environments
– Label ‘patient safety game master’ eg those who have identified a new hazard or part of a group which has seen a project to fruition
– Avatars could have details attached to them – what hazards identified, groups in, scores, history, background
– Simple to use using all forms of media – Facebook, twitter, email etc
– Front end looks extremely appealing
– Simple to navigate with minimal clicks to further info
– People entering data feel secure (don’t need to provide their details – could be made up info yet anyone within that hospital can verify the info and change)
– ?Can see how many & which avatars logged in & playing so can converse with them?
End
Welcome to the PatientSafe Game
Our goal is to ensure all patients are looked after in the best possible environment.
The rules are simple
Front line staff (as avatars) provide information about their work environments and what could be improved.
Specific focus will be on ‘sub games’ which look at the equipment and systems staff are interacting with
Pieces of equipment have been provided with a score dependent on their usability. (This score has been generated transparently by human factors experts working in collaboration with front line staff and others)
The overall scores for each hospital will be tallied. Influential staff (CEO, procurement heads, departmental heads) from each hospital will be provided with feedback on how they have performed and what they might do to improve.
All hospitals are involved. Information can be provided by anyone – patient to hospital CEO)
Scoring system example:
3 points for doing the right thing (can whatever scoring scale we choose dependent on the game)
1 point if doing the wrong thing (bad news demonstrates there’s a willingness to change & improve)
0 points if not taking part in a particular challenge
Challenges are set by an independent collaborative group of healthcare staff and system safety experts. (Using BaseCamp group already set up which can increase in size as needed – already has several front line healthcare staff and human factors experts within it)
We will keep a list of the challenges (click on each to read more including presentations) and how each hospital is faring. If you would like to discuss a challenge further then please do get in touch.
Welcome to the ‘PatientSafe Game’ – we’re here for you.
These challenges might be good for starters then we could add to them:
– Valved IV fluid bags – https://wp.me/p8r3e4-5q
– Chlorhexidine – https://wp.me/p8r3e4-x6
– BVM expiratory valve – https://wp.me/p8r3e4-mX
– Anaesthetic circuit filter
– (IV paracetamol collapsible bags) – https://wp.me/p8r3e4-7O
– ISO standard enteral feeding tube connections – https://wp.me/p8r3e4-6n
These initial challenges have been chosen as staff very unlikely to have emotional attachment to alternatives, either cost saving or cost neutral at from end, little if any evidence required to understand why they’re better, superior devices already used so tried and tested in many hospitals already.
Hooks
– make it fun
– regular update messages – new hospitals entering, where own hospitals are in ranking, new games created
– any individual can play the more who register for a particular hospital the more fractions of a point that hospital receives – fraction can relate to size of hospital by eg staff numbers (one player can register for one hospital once yet can register for several hospitals). (Players who enter incorrect info on purpose can be locked out if it doesn’t agree with majority info)
– forum – chat with others about how got hospitals to change. Messages when hospital has made a change which your hospital needs to make & how it was done.
– Presentation links to give to hospitals about need for change for particular item
– The earlier you get in the higher you’ll be on the leader board compared to place with similar score (still registered as eg equal first if same score as first place but on leader board name will appear earlier)
– reverse exponential release of rewards ie lots initially when start playing then less and less frequent (eg time between new challenges could gradually be longer and longer – known as variable ratio schedule of reinforcement) also vary the length of any one game session – forces you to wait before jumping in again
– Make them super quick, easy to get in to and learn, incredibly fun and rewarding sound and graphical design
– honourable mentions, honours list, extra scores for engagement & involvement with human factors discussions & developing new projects,
– Include forums for people to tell de-identified stories and suggest improvements in hospital environments
– Label ‘patient safety game master’ eg those who have identified a new hazard or part of a group which has seen a project to fruition
– Avatars could have details attached to them – what hazards identified, groups in, scores, history, background
– Simple to use using all forms of media – Facebook, twitter, email etc
– Front end looks extremely appealing
– Simple to navigate with minimal clicks to further info
– People entering data feel secure (don’t need to provide their details – could be made up info yet anyone within that hospital can verify the info and change)
Thanks, Rob
By the way I have no financial links with any of the equipment discussed and this would need to be funded solely by money’s I can get my hands on
This is me: http://www.dailymail.co.uk/news/article-5169791/Sydney-Dr-Rob-Hackett-puts-profession-cap.html
This is why: https://wp.me/p8r3e4-vm
Happy to have advertising, direct links to Osler & even use Osler (or similar) as part of one of the challenges if the independent group agree.
Make it look like an independent site but you’ve got control over it (then no concerns about initial negative impact on Osler itself). The more it becomes established and accepted the more you may want to reveal involvement & links eg part of a package aimed at improving patient outcomes, ensuring staff have competence and ready access to info. Could even introduce international auditing eg of central lines (de identified)
Steven Shorrock
Gordon French
Niall Downey
Human Problem (P) & Design Solution (S)
P. Mistaking indistinct pourable chlorhexidine for colourless solutions & injecting it in to patients
S. Ban indistinct pourable chlorhexidine & replace with vivid and/or contained solutions
100 points if institution does not have indistinct pourable chlorhexidine
Link: https://wp.me/p8r3e4-t
P. Re-spiking IV fluid bags allowing air entrainment risking air embolus deaths
S. Use cheaper valves IV fluid bags which don’t entrain air
100 points if using only valved IV fluid bags
Link: https://wp.me/p8r3e4-5q
P. Poor pre-oxygenation through using BVM without expiratory valve
S. Ensure & standardise all BVM to have a fixed expiratory valve
200 points if hospital only using BVM with fixed expiratory valve
Link: https://wp.me/p8r3e4-mX
P. Air entry to giving sets via bottled intravenous paracetamol
S. Use only IV paracetamol in bags
100 points if only using bags of IV paracetamol
Link: https://wp.me/p8r3e4-7O
P. Routine cannula replacement policy places unnecessary & detrimental work load on front line staff
S. Introduce an as indicated peripheral cannula replacement policy system
500 points if policy exists/implements to remove cannulae as indicated
Link: https://wp.me/p8r3e4-6d
P. Mistaken or unable to identify & name staff members quickly impairing optimal teamwork
S. Ensure all staff have their name & role clearly displayed (in OR best option is labeling on surgical hat)
5 points for each staff member in theatre with a hat with their name & role on
500 points if it becomes policy at that institution
Link: https://vimeo.com/242437507
P. Imperfect decision making as to when to use a VL or DL
S. For laryngoscopy Use VLDL first line every time
200 points if VLDL available at all intubation locations
Link: https://wp.me/p8r3e4-d5
P. Accidental disconnection of central lines leaving them open to air & risking air embolus deaths
S. Only use central lines and attachments with bonded valves which can’t be left accidentally open to air
250 points if commence trial of CVCs with bonded valves
250 points if remove all vascular device attachments which open to air
Link: https://wp.me/p8r3e4-br
P. Accidentally trapping APL valve on Draeger machine open causing catastrophic inability to ventilate patients
S. Free replacement & recall of pre 2010 Draeger APL valves with their beveled version
(Already fixed in Australia – have 100 points each)
Link: https://wp.me/p8r3e4-cL
P. Locked sugammadex causes unnecessary delays in obtaining it detrimentally impairing patient management decisions
S. Ensure a box of sugammadex is readily available during theatre lists on Anaesthetic trolley
200 points if box sugammadex readily available on all anaesthetic theatre trolleys during list
Link: https://wp.me/p8r3e4-1a
50 Points for coming up with accepted system safety solutions to add to this list (e.g. Circuit filters without detachable cap which falls in airway)
250 Points for commencing trials/pilot studies reviewing system safety solutions e.g. trialling ETO2 monitoring in ED, trialling continuous monitoring for patients on PCA
Avatars
St George Private – Georgie
RPA – Alfie
Crows Nest Day Surgery – Crowy
Stratified – Strattie
Chatswood Private – Chatty
Sydney Dental Hospital – Denny
Different leagues depending on Hospital / Day Surgery etc
People in general enjoy being part of a team and healthy competition. They like to feel safe, included and have a sense of purpose.
Avatars allow some safety. Positive reinforcement. Healthy competition.
St George Private – Georgie
RPA – Alfie
POWH – Charlie
Crows Nest Day Surgery – Crowy
John Hunter – Johny
Coffs Harbour – Coffee Club
Stratified – Strattie
Chatswood Private – Chatty
5 points for each staff member in theatre with a hat with their name & role on
500 points if it becomes policy at that institution
Add more system safety solutions
Points for coming up with accepted system safety solutions
Points for commencing trials/pilot studies reviewing system safety solutions
Points for filling in feedback forms assessing quality of equipment types
Maslow
Safety (avatar)
Competition safety
Inclusion
Longing for connection
Miss Alison Brindle – Midwife UK
Mrs Marie Nemani – Medical Student UK
Miss Jo Lever – Nurse UK
Mr Satyan Chari – Lead Safety & Quality Systems Australia
Mr Steven Shorrock – Human Factors and Ergonomics Expert UK
Dr Gordon French – Consultant Anaesthetist UK
Dr David Gillespie – Consultant Anaesthetist Australia
Dr David Bell – Consultant Anaesthetist Australia
Dr Rhys Thomas – Quality and Safety Fellow in Anaesthesia Australia
Dr Stuart Marshall – Consultant Anaesthetist with special interest in Simulation & Human Factors Australia
Dr Todd Fraser – Intensivist. Director of Osler Technology. Australia
Yeshwanth Pulijala – Founder & CEO of Scalpel LTD
Dr Rob Hackett – Consultant Anaesthetist Australia