This is a guest post by Dr Casey Parker (@BroomeDocs) of BroomeDocs.com
So what is a CROCODILE? Not a large estuarine reptile – but a way to learn from our mistakes and adverse outcomes.
Confidential Review Of Critical Outcomes and Dodgy Incidents for Learning and Edification
Our junior medical officers (JMOs) work with a team of generalists with a wide range of skills and experience. It is a busy little ED where there is often little time to reflect and contemplate how to improve outcomes or examine errors to learn how to do better.
We developed the CROCODILE as a “closed-door” forum where we could put critical incidents and poor outcomes under the microscope to try and share experience and learn from our mistakes in a safe, non-confronting format. The idea is based on the old M&M meetings that were popular in the surgical units a few years back.
We examine all sorts of clinical decisions, communication, and supervision problems in order to get at the root of our errors. Specific incidents are identified by the JMOs or by senior staff, then once a week we ask the JMO involved to present the case, the critical decisions and any errors or poor outcomes that occur. It is a bit of a confessional, with the group then able to give their opinions, share similar experiences and problems to try and arrive at a general rule that we can use in the future.
In northern Australia where we live there are two types of crocodiles – “freshies” and “salties”. Freshwater crocs are cute, little guys that might give you a nip on the ankle but usually leave people alone. Saltwater crocs are not so cute, they tend to eat tourists (see Tropical Trouble: Straight from the Crocodile’s Mouth)
Likewise there are 2 types of errors we discuss – “freshies” are those small, trivial, day-to-day errors that we all make but usually do not arrive at serious harm. “Salties” on the other hand are big, serious errors – the ones that can do serious harm if committed or unrecognised.
The forum offers the JMOs an opportunity to feedback to the senior doctors ‘en masse’ – therefore removing the personality or specific interpersonal problems from the equation. This also allows me, as training director, to identify specific problems with our supervision model in the ED.
I hope that our JMOs will learn how systematic self-examination can improve practice. I also hope that common errors can be shared and hopefully not repeated by each JMO as they embark on their learning in new areas of practice.
We have been doing this for a few months now and the JMOs really get into it – they have developed a collegial bond and trust, with a productive outlet for the little frustrations that being a trainee in ED inevitably involves.
Maybe you can try this in your hospital?
About the Author
Learning from mistakes is truly a great way of learning to improve doctor’s skills.
I dream of the day that this-a-like comes to an online, multi-national, closed forum. Google+ has the potential with it’s closed Circles system but I guess it will take docs a while to get used to the idea…
Good model – this could and should be embedded in all departments or hospitals,inc the smaller rural ones. Sadly has not been my experience, but I reckon we’ll give this model a go locally…may have to use the medical students to drive it, rather than us VMOs. Now the only challenge will be to bridge the us/them mentality between us as private VMOs and the public system, with the latter usually seeing error as a fault whereby ‘someone must be blamed’…or preferring to ignore foreseeable risk due to financial constraints.
Ho hum
Tim,
I think the format is good – but relies on a “chair” – somebody who can direct, moderate and facilitate the group to come up with practical / realistic and actionable solutions to problems.
As the “chair” you need to be humble, self-deprecating and prepared to cop a bit of criticism yourself.
The “closed-door” rules need to be laid out clearly for all the participants to ensure they feel safe and actually come forward with cases / suggestions.
I have found it was a bit slow to start with but now the JMOs actually seek me out to identify cases they want to discuss.
With regard to conflicting interests with different docs (private, public, OTds etc): the discussion and cases are ALL about patient safety, well-being and improving care. Politics, money and legal risk are distant or non-existent considerations. If you make this clear in the initial set-up and chair it strongly then it becomes a faux pas to mention non-clinical risk etc. Keep it “patient-centered” and it will stay on track – after all it is the one objective we all have in common!
Good luck.
Casey