De-freezing frozen patient management

Kobo-Greenhut, Ayala; Shnifi, Amin; Tal-Or, Eran; Magnezi, Racheli; Notea, Amos; Ruach, Meir; Onn, Erez; Cohen, Ayala; Doveh, Etti; Shlomo, Izhar Ben; Hasin, Y.

doi:10.1093/intqhc/mzy010

Cited by 3 publications

(1 citation statement)

References 21 publications

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“…The latter leads to much learning and requires leaping from one learning behavior (LB) to another. [1][2][3][4] LB consists of activities through which data are obtained and processed. Frequent arrival of new protocols should result in frequent leaping from one LB to another.…”

Section: To the Editormentioning

confidence: 99%

Letter to the Editor: Time-Out Protocol to Ensure Understanding and Implementation of the Storm of Instructions and Protocols During the COVID-19 Pandemic

Kobo-Greenhut¹,

Arad²,

Levi-Hevroni³

et al. 2020

Am J Med Qual

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Section: To the Editormentioning

confidence: 99%

Letter to the Editor: Time-Out Protocol to Ensure Understanding and Implementation of the Storm of Instructions and Protocols During the COVID-19 Pandemic

Kobo-Greenhut¹,

Arad²,

Levi-Hevroni³

et al. 2020

Am J Med Qual

Self Cite

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Stop! Check your initial assumptions

Kobo-Greenhut

Sakas²,

Magnezi³

et al. 2017

Medicine

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At times, leaping from one patient management routine to an alternative one may be required to mitigate medical errors. “Frozen patient management” is the resultant situation, when, in the face of an obvious gap between the expected and the actual phenomena, leaping from current patient management to an alternative one is not considered or done. Frozen patient management can lead to a significant delay of the correct definitive intervention, be it surgical or pharmacological. The significance of this delay is especially important in time-dependent dynamic situations. In delivery ward, this may cost the life of either the fetus or the mother.In this study, we describe a sequence in which frozen patient management occurred in the delivery ward. Using “thinking protocol” (herein termed “de-freezing” questionnaire) made the team stop and consider a leap when gaps became apparent, and saved the mother's life.We believe that adopting the “de-freezing questionnaire” as a routine adjunct for all medical activities would lead to a timely change of treatment line, which, in turn, will save lives and unnecessary suffer.

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Better patient safety: implementing exploration and exploitation learning in daily medical practice

2017

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BackgroundCurrent medical daily practice relies on guidelines, protocols and procedures (GPPs), which require exploitation. However, diagnosis, treatment, risk management and process improvements require exploration. Physician are often unable to switch between exploitation and exploration. This study tested a new approach to facilitate switching that included (1) a new ‘thinking protocol’ that encouraged leaping from exploitation to exploration and (2) a GPP that encouraged leaping from exploration to exploitation.MethodTwo hundred students were divided into four groups. The groups received a set of tasks that required switching between exploitation and exploration. Three groups received the thinking protocol, the GPP, or both, and the fourth group served as control.ResultsWith each additional task, all groups increased exploitative tendency(p<0.0001). The two groups with the thinking protocol leaped from exploitation to exploration (p<0.0001); the other two groups remained in exploitation (p=0.1173, p=0.0758). For the groups that employed exploration learning, the group that received the GPP switched back to exploitation (p<0.0001), but the other group remained in exploration (p=0.2363).ConclusionDespite the importance of timely leaping between exploration and exploitation, in some events, medical teams fail to make the appropriate leap. We suggest to use our novel approach and to encourage the leaping between exploration and exploitation in daily medical practice, to enable the prevention of medical errors and to enhance the effectiveness of risk managements and process improvements.

show abstract

De-freezing frozen patient management

Cited by 3 publications

References 21 publications

Letter to the Editor: Time-Out Protocol to Ensure Understanding and Implementation of the Storm of Instructions and Protocols During the COVID-19 Pandemic

Letter to the Editor: Time-Out Protocol to Ensure Understanding and Implementation of the Storm of Instructions and Protocols During the COVID-19 Pandemic

Stop! Check your initial assumptions

Better patient safety: implementing exploration and exploitation learning in daily medical practice

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