Approaches to Healthcare Event Analysis
|
|
|
- Cori Ryan
- 5 years ago
- Views:
Transcription
1 October 15, 2015 Approaches to Healthcare Event Analysis Partnering for Improvement Ellen S Deutsch, MD, MS, FACS, FAAP Medical Director
2
3
4
5
6 Healthcare systems are complex adaptive systems Complexity Threats Resilience
7 Healthcare systems - from microsystems to organizations are complex adaptive systems Complexity is a feature of the system as a whole, not necessarily of each component inside it Networks include many agents each of whom constantly acts, and reacts to the others Systems are influenced by the environment in which they operate, and influence that environment Environment is not in equilibrium Constant evolution, with fluid, dynamic changes Interactions are non-linear; small events can produce large results Control is highly dispersed and decentralized Dekker, Drift into Failure; Charles Vincent, Patient Safety
8 Safety is not inherent in systems The systems themselves are contradictions between multiple goals that people must pursue simultaneously. People have to create safety. Attributed to Dekker 2002 and Hollnagel & Woods 2005, by Holden RJ. People or systems? To blame is human. The fix is to engineer. Prof Saf 2009
9 Failure Modes and Effects Analysis Impact Frequency Minor Moderate Catastrophic Rare Occasional Frequent Additional consideration: detectability
10 Root Cause Analysis 5 Whys Ishikawa fishbone diagram Veterans Administration National Center for Patient Safety: What, Why, What, How National Patient Safety Foundation: RCA 2 Improving Root Cause Analysis and Action to Prevent Harm
11 Audience response questions Do you aggregate or conduct annual reviews of your RCA findings? ("Common Cause Analysis") Do you have a formal follow-up process for your RCA recommendations? (i.e. 6 or 12 months later) Do you use simulation as a component of RCAs?
12 Simulation to investigate incidents or serious events Simulation of medication administration using actual equipment revealed: Dose double-check protocol not well understood The infusion pump stuttered (duplicated a keystroke), delivering 22.3 mg, rather than 2.3 mg
13 In situ simulation can help us understand and improve Work as Done Work as imagined Work as Done Work as abstracted Work as simulated
14 In theory there s no difference between theory and practice. In practice there is. Yogi Berra ( )
15 There s rules to riding a horse But the horse won t necessarily know em Texas Bix Bender
16 Employees must wash hands really?
17 To err is human To err is human: building a safer health system. Institute of Medicine 1999 To err is human, don t forget Pat Croskerry, CMAJ March 2010
18 The search for a human in the path of a failure is bound to succeed. If not directly at the sharp end as a human error or unsafe act one can usually be found a few steps back. The assumption that humans have failed therefore always vindicates itself. Hollnagel, E.; Woods, DD. Joint Cognitive Systems: Foundations of Cognitive Systems Engineering
19 It's not bad people it's bad systems Lucian Leape. NPSF conference April To better is human Terry Fairbanks. MedStar Health National Center for Human Factors in Healthcare medicalhumanfactors.net accessed Nov 2, 2014 To blame is human. The fix is to engineer Holden RJ. People or systems? To blame is human. The fix is to engineer. Prof Saf 2009
20 People working in health care are among the most educated and dedicated work force in any industry The problem is not bad people, the problem is that the system needs to be made safer Preventing errors and improving safety for patients require a system approach in order to modify the conditions that contribute to errors To Err is Human. IOM 2000
21 Threats to our patients Situation I: Regular threat Occurs often enough to develop a standard response e.g. ACLS, PALS A typology of Resilience Situations by Ron Westrum in Resilience Engineering: Concepts and Precepts
22 Threats to our patients Situation II: Irregular threat Unexpected but not impossible or unimaginable Requires improvisation A typology of Resilience Situations by Ron Westrum in Resilience Engineering: Concepts and Precepts
23 Threats to our patients A typology of Resilience Situations by Ron Westrum in Resilience Engineering: Concepts and Precepts
![Resilience refers to a property of organizations, as well as individuals, which have the ability to recognize, and adapt to handle unanticipated perturbations [which] demand a shift of processes,](/docs-images/90/104373049/images/24-0.jpg "strategies, and coordination.")
24 Resilience refers to a property of organizations, as well as individuals, which have the ability to recognize, and adapt to handle unanticipated perturbations [which] demand a shift of processes, strategies, and coordination. Four essential capabilities of resilience: Monitor: know what to look for Respond: know what to do, be capable of doing it Learn: know what has happened Anticipate: find out; know what to expect Woods D. Essential Characteristics of Resilience in Hollnagel, Woods, Leveson eds. Resilience Engineering Concepts and Precepts Photo: NYPost / AP
25 Safety-I and Safety-II Safety-I What goes wrong Safety-II: What goes right Hollnagel, Wears, Braithwaite, 2015
26 Equitable Patient-centered Engaged Quality Reliable Safe, Effective Expert Respectful Value Timely Standardized Efficient
27
28 Questions? Thank You Ellen S Deutsch edeutsch@ecri.org
6/17/2014. Resilient health care: forging new directions. Australian Institute of Health Innovation s mission
Question 1: what s your definition of resilience, please? Resilient health care: forging new directions Australian Institute of Health Innovation Professor Jeffrey Braithwaite, PhD Professor of Health
Understanding the Causes of Events. Objectives
Introduction to Root Cause Analysis (RCA) Understanding the Causes of Events HSAG Pressure Ulcer Collaborative August 19, 2009 Andrea B. Silvey, PhD, MSN HSAG Chief Quality Improvement Officer 1 Objectives
Creating a Highly Reliable Health System: the Leadership Challenge. 6 th Annual Patient Safety Symposium Rick Foster, MD
Creating a Highly Reliable Health System: the Leadership Challenge 6 th Annual Patient Safety Symposium Rick Foster, MD April 18, 2013 Moving Toward Zero It may seem a strange principle to enunciate as
Walking the Tightrope with a Safety Net Blood Transfusion Process FMEA
Walking the Tightrope with a Safety Net Blood Transfusion Process FMEA AnMed Health AnMed Health, located in Anderson, South Carolina, is one of the largest and most technologically advanced health systems
9/9/2016. How Respiratory Therapist Enhance Patient Safety. Introduction. Raise your hand. Tawana Shaffer CPHRM, MBA, BSc, CRT
How Respiratory Therapist Enhance Patient Safety Tawana Shaffer CPHRM, MBA, BSc, CRT Introduction Raise your hand 1 How do you define Patient Safety? What is Patient Safety? Communication Care Falls Outcomes
COOK COUNTY HEALTH & HOSPITALS SYSTEM
COOK COUNTY HEALTH & HOSPITALS SYSTEM CCHHS Board of Directors Quality and Patient Safety Committee Quality and Reliability in Health Care Krishna Das, MD, Chief Quality Officer 15 March 2016 Quality:
Applying a human factors approach
AUSTRALIAN INSTITUTE OF HEALTH INNOVATION Faculty of Medicine and Health Sciences Applying a human factors approach to improve the quality of health care 2 Applying a human factors approach to improve
RCA in Healthcare 3/23/2017. Why Root Cause Analysis is Performed. Root Cause Analysis in Healthcare Part - 1. Contd. Contd.
Why Root Cause Analysis is Performed Root Cause Analysis in Healthcare Part - 1 Prof (Col) Dr R N Basu Executive Director Academy of Hospital Administration Kolkata Chapter The goal of the root cause analysis
Resilience in Healthcare
Resilience in Healthcare The Other Side of Human Error Dr Carl Horsley, Critical Care Complex, Middlemore Hospital Patient Safety Staff Safety Outline The current model of safety The problems with the
Preventing Medical Errors
Presents Preventing Medical Errors Contact Hours: 2 First Published: March 31, 2017 This Course Expires on: March 31, 2019 Course Objectives Upon completion of this course, the nurse will be able to: 1.
Text-based Document. The Culture of Incident Reporting Among Filipino Nurses. de Guzman, Barbara Michelle. Downloaded 28-Apr :54:41
The Henderson Repository is a free resource of the Honor Society of Nursing, Sigma Theta Tau International. It is dedicated to the dissemination of nursing research, researchrelated, and evidence-based
Building a Safe Healthcare System
Building a Safe Healthcare System Objectives 2 Discuss the process of improving healthcare systems. Introduce widely-used methodologies in QI/PS. What is Quality Improvement? 3 Process of continually evaluating
Understanding the High Reliability Organization and Why It's Important to Your Lab
Understanding the High Reliability Organization and Why It's Important to Your Lab Jennifer Rhamy MBA, MA, MT(ASCP)SBB, HP Executive Director, Laboratory Accreditation High Reliability Organization (HRO)
A culture of safety is a culture of compassion
A culture of safety is a culture of compassion Compassion in Action Webinar Series March 21, 2017 1 Moderator Andrea Greenberg Communications and Partnerships Associate The Schwartz Center for Compassionate
Medication Safety in LTC. Objectives. About ISMP Canada
Medication Safety in LTC Part II -Vulnerabilities in the Medication Use Process and Strategies to Enhance Medication Safety Lynn Riley, RN ISMP Canada Thursday, October 20, 2011 Objectives At the end of
Using the Just Culture Method. Stacey Thomas, BSN, RNC Risk Analyst
Using the Just Culture Method Stacey Thomas, BSN, RNC Risk Analyst Just Culture A system of Shared Accountability Everyone in the organization is responsible for maintaining a safe and reliable system
According to Lucian Leape, Professor of Health Policy at
A Statewide Approach to a Just Culture for Patient Safety: The Missouri Story Rebecca Miller, MHA, CPHQ, FACHE; Scott Griffith, MS; and Amy Vogelsmeier, PhD, RN The Missouri Just Culture Collaborative
Unlocking the potential of resilience in healthcare: using workarounds to expose what being good at their job means for nurses
Unlocking the potential of resilience in healthcare: using workarounds to expose what being good at their job means for nurses Deborah Debono, Robyn Clay-Williams, Natalie Taylor, David Greenfield, Jeffrey
A Human Systems Integration Framework for Safe Patient Handling and Mobility Outcomes for Patients and Care Providers
A Human s Integration Framework for Safe Patient Handling and Mobility Outcomes for Patients and Care Providers Pascale Carayon, Ph.D. Center for Quality and Productivity Improvement Department of Industrial
Blood Sample Labeling Shean Strong, QI Director Lisle Mukai, QI Coordinator
Blood Sample Labeling Shean Strong, QI Director Lisle Mukai, QI Coordinator Presented at Webex Conferences: July 20, 21, & 22, 2010 Blood Sample Labeling Seminar 6255 West Sunset Blvd Los Angeles, CA Blood
Engaging Leaders: From Turf Wars to Appreciative Inquiry
Engaging Leaders: From Turf Wars to Appreciative Inquiry Principles of Leadership for a Quality and Safety Culture Harvard Safety Certificate Program 2010 Gwen Sherwood, PhD, RN, FAAN Gwen Sherwood, PhD,
Safety Measurement, Monitoring & Strategies
Safety Measurement, Monitoring & Strategies Jonkoping Microsystem Festival Scientific Day March 2016 Charles Vincent Professor of Psychology University of Oxford Lead Oxford AHSN Patient Safety Collaborative
Just Culture. The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.
Just Culture November 2016 Just Culture The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes. Dr Lucian Leape Harvard School of Public
Cognitive Level Certified Professional in Patient Safety Detailed Content Outline Recall. Total. Application Analysis 1.
Cognitive Level Certified Professional in Patient Safety Detailed Content Outline Recall Application Analysis Total 1. CULTURE 2 12 4 18 A. Assessment of Patient Safety Culture 1. Identify work settings
4. Hospital and community pharmacies
4. Hospital and community pharmacies As FIP is the international professional organisation of pharmacists, this paper emphasises the role of the pharmacist in ensuring and increasing patient safety. The
The Importance of Transfusion Error Surveillance This is step #1 in error management. Jeannie Callum, BA, MD, FRCPC, CTBS
The Importance of Transfusion Error Surveillance This is step #1 in error management Jeannie Callum, BA, MD, FRCPC, CTBS 6051 Clinical Errors 9083 Laboratory Errors 15134 Errors over 6 years I don t want
Intravenous Infusion Practices and Patient Safety: Insights from ECLIPSE
Intravenous Infusion Practices and Patient Safety: Insights from ECLIPSE Acknowledgement and disclaimer Funding acknowledgement: This project is funded by the National Institute for Health Research Health
Using MEDMARX for Reporting and Benchmarking. Anne Skinner, RHIA Katherine Jones, PhD, PT
Using MEDMARX for Reporting and Benchmarking Anne Skinner, RHIA Katherine Jones, PhD, PT Purpose of the Grant: Assist small rural hospitals to Voluntarily report and analyze medication errors Identify
What Every Patient Safety Officer Must Know:
What Every Patient Safety Officer Must Know: Tapping into the Best Resources in the Country John R. Combes, MD Senior Medical Advisor Hospital and Healthsystem Association of Pennsylvania Harrisburg, PA
TREATMENT OF MEDICAL ERROR ISSUES AT SURGICAL M&M CONFERENCE. Prof. Alberto R. Ferreres, MD, FACS
TREATMENT OF MEDICAL ERROR ISSUES AT SURGICAL M&M CONFERENCE Prof. Alberto R. Ferreres, MD, FACS MEDICAL ERROR IN M&M CONFERENCE MEDICAL ERROR AT M&M CONFERENCE LA RESPONSABILIDAD MEDICA Y LA PRACTICA
Patient Safety: 10 Years Later Why is Improvement So Hard? Patient Safety: Strong Beginnings
Patient Safety: 10 Years Later Why is Improvement So Hard? G. Ross Baker, Ph.D. Institute of Health Policy, Management & Evaluation University of Toronto 3 November 2014 Patient Safety: Strong Beginnings
Enhancing Patient Quality and Safety with Compliance
Enhancing Patient Quality and Safety with Compliance April 23, 2013 John Kalb, JD, CCEP, CHPC Operational Excellence Executive/ Compliance Officer Kootenai Health Content A successful compliance program
Preface: On the Need for Resilience in Health Care
Preface: On the Need for Resilience in Health Care Erik Hollnagel, Jeffrey Braithwaite and Robert L. Wears This book provides the first comprehensive description of resilient health care, henceforth referred
Your guide to managing risk at events
Your guide to managing risk at events What does managing risk mean? The main purpose of managing risk is to reduce the likelihood of any staff, volunteers or participants involved in a Christian Aid event
National Health Regulatory Authority Kingdom of Bahrain
National Health Regulatory Authority Kingdom of Bahrain THE NHRA GUIDANCE ON SERIOUS ADVERSE EVENT MANAGEMENT AND REPORTING THE PURPOSE OF THIS DOCUMENT IS TO OUTLINE SERIOUS ADVERSE EVENTS THAT SHOULD
From Value to High-Reliability Organization
From Value to High-Reliability Organization William R Mayfield MD, FACS Chief Surgical Officer WellStar Health System ACS NSQIP Chicago July 2015 No disclosures Outline Origins of the High-Reliability
National Patient Safety Goals Effective January 1, 2016
National Patient Safety Goals Effective January 1, 2016 Goal 1 Improve the accuracy of patient identification. NPSG.01.01.01 Home are Accreditation Program Use at least two patient identifiers when providing
Human Factors and Ergonomics in Health Care and Patient Safety
Human Factors and Ergonomics in Health Care and Patient Safety Pascale Carayon, Ph.D. Procter & Gamble Bascom Professor in Total Quality Department of Industrial and Systems Engineering Director of the
Care of the Caregiver STARTS and ENDS with full leadership support and involvement!
Care of the Caregiver STARTS and ENDS with full leadership support and involvement! Care of the caregiver following an unintentional error or near miss should ideally incorporate: Unsafe Acts Algorithm
Systems Thinking & Human Factors Engineering in Healthcare
Clinical Networks and Streams and Managers John Hunter Hospital Newcastle, NSW; August 10, 2015 Systems Thinking & Human Factors Engineering in Healthcare Rollin J. (Terry) Fairbanks, MD, MS Director,
Human Reliability Analysis in Healthcare
45 Human Reliability Analysis in Healthcare Joe Deeter 1 and Esa Rantanen Rochester Institute of Technology, Rochester, NY, USA 1 Now Rochester General Health System Institute for Patient Safety The problem
A GLOWING RESEMBLANCE A COMPARE AND CONTRAST OF MEDICAL AND NUCLEAR PERFORMANCE IMPROVEMENT INITIATIVES
A GLOWING RESEMBLANCE A COMPARE AND CONTRAST OF MEDICAL AND NUCLEAR PERFORMANCE IMPROVEMENT INITIATIVES 23 rd Annual HPRCT Conference June 12-15, 2017 Thomas Diller, MD, MMM; Executive Director University
QI TALK TIME. Building an Irish Network of Quality Improvers. Leading for Quality. Speaker: Peter Lachman ISQua CEO. 21st Nov 2017
QI TALK TIME Building an Irish Network of Quality Improvers Leading for Quality Speaker: Peter Lachman ISQua CEO 21st Nov 2017 Connect Improve Innovate Speaker Peter Lachman - M.D. MPH. M.B.B.Ch., FRCPCH,
Innovative Techniques for Residents to Improve Safety
Innovative Techniques for Residents to Improve Safety Eugene Terry, MD Modified from Tammy Lundsrum,MD www.mihealthandsafety.org/presentations/lundstrom.ppt What is a Safety Culture And how is it achieved?
Medical Malpractice Risk Factors: An Economic Perspective of Closed Claims Experience
Research Article imedpub Journals http://www.imedpub.com/ Journal of Health & Medical Economics DOI: 10.21767/2471-9927.100012 Medical Malpractice Risk Factors: An Economic Perspective of Closed Claims
Root Cause Analysis. Why things happen
Root Cause Analysis Why things happen Secret There is really no such thing as a root cause There are contributing factors and there is no end to them Purpose of a Root Cause Analysis The purpose is to
Resilience in Health Care
Resilience in Health Care Erik Hollnagel, Ph.D. Professor, University of Southern Denmark Chief Consultant, Center for Kvalitet, Region of Southern Denmark E-mail: erik.hollnagel@rsyd.dk There is something
Patient Safety Overview Muhammad H. Islam, MBBS, MS, MCH Director of Patient Safety & Patient Safety Officer SUNY Downstate Medical Center, UHB
Patient Safety Overview Muhammad H. Islam, MBBS, MS, MCH Director of Patient Safety & Patient Safety Officer SUNY Downstate Medical Center, UHB www.downstate.edu/patientsafety Definitions Patient Safety
Quality Improvement Overview. Paul vanostenberg, DDS. MS Vice President Accreditation and Standards Joint Commission International
Quality Improvement Overview Paul vanostenberg, DDS. MS Vice President Accreditation and Standards Joint Commission International The History of Improving We are perfect! Get rid of the bad apples! System
Patient Risk (Safety) in Radiation Therapy
Patient Risk (Safety) in Radiation Therapy Michael G. Herman, Ph.D. Professor and Chair, Medical Physics Mayo Clinic Patient Safety 10/18/11 Herman # 1 Outline Radiation Therapy What Can/Did Happen? Is
Disclosure. Institute of Medicine (IOM) 1,2. Objectives 5/15/2014. Technician Education Day May 24, 2014 Ft. Lauderdale, FL
Technician Education Day May 24, 2014 Ft. Lauderdale, FL The Pharmacy Technician s Role in Keeping Our Patients Safe Antonia Zapantis, MS, PharmD, BCPS Associate Professor, Nova Southeastern University
Open Disclosure. Insert Logo Here. For more information, contact:
Open Disclosure What s it about? Encouraging open and effective communication with patients. Acknowledging that adverse events causing harm occur. Saying sorry to the patient for any harm suffered during
Culture of Safety: What s in Your Toolbox?
Culture of Safety: What s in Your Toolbox? Kathy Ghomeshi, PharmD, BCPS Medication Safety Specialist Victoria Serrano Adams, PharmD, FASHP, FCSHP Director of Pharmaceutical Services UCSF Medical Center
CAMPAIGN OPPORTUNITIES. Creating a world where patients and those who care for them are free from harm npsf.org
CAMPAIGN OPPORTUNITIES Creating a world where patients and those who care for them are free from harm npsf.org DID YOU KNOW: Studies suggest that preventable harm in health care is a leading cause of death.
Incident Reporting Systems and Future Strategies for Patient Safety Improvement
WHITE PAPER: Incident Reporting Systems and Future Strategies for Patient Safety Improvement Author: Datix Date: 2016/17 Driving down harm How can healthcare providers most successfully pursue the goal
Degree to which expectations of participants were met regarding the setting and delivery of the educational activity
Outcomes Framework Miller s Framework Description Data Sources and Methods Participation LEVEL 1 Number of learners who participate in the educational activity Attendance records Satisfaction LEVEL 2 Degree
Medical Emergency Preparedness in Primary Care. Eman Sharaf, MD, Arab Board FM, Clinical Fellowship Emergency*
1 Bahrain Medical Bulletin, Vol. 32, No. 3, September 2010 Family Physician Corner Medical Emergency Preparedness in Primary Care Eman Sharaf, MD, Arab Board FM, Clinical Fellowship Emergency* Since the
The importance of applying human factors to nursing practice
The importance of applying human factors to nursing practice Norris B et al (2012) The importance of applying human factors to nursing practice. Nursing Standard. 26, 32, 36-40. Date of acceptance: December
Letitia Cameron, MD Aniel Rao, MD Michael Hill, MD
Presented by: Suchita Pancholi, MD Letitia Cameron, MD Aniel Rao, MD Michael Hill, MD I. Introductions II. III. IV. Marshmallow Challenge Why Teach Patient Safety? Barriers to Teaching Patient Safety V.
May Improving Strategic Management of Hospitals: Addressing Functional Interdependencies within Medical Care Paper 238
A research and education initiative at the MIT Sloan School of Management Improving Strategic Management of Hospitals: Addressing Functional Interdependencies within Medical Care Paper 238 Masanori Akiyama
The Power of Quality. Lindsay R. Smith, MSN,RN Quality Manager Vanderbilt Transplant Center
The Power of Quality Lindsay R. Smith, MSN,RN Quality Manager Vanderbilt Transplant Center What do you think of when you hear the word quality? LEAN RCA PDSA QAPI SIX SIGMA PIP TQM 5s Objectives Transplant
Running head: MEDICATION ERRORS 1. Medications Errors and Their Impact on Nurses. Kristi R. Rittenhouse. Kent State University College of Nursing
Running head: MEDICATION ERRORS 1 Medications Errors and Their Impact on Nurses Kristi R. Rittenhouse Kent State University College of Nursing MEDICATION ERRORS 2 Abstract One in five medication dosages
Karen M. Mathias, MSN, RN, APRN-BC Director Barbara J. Peterson, RN Simulation Specialist
On the Rural Roads with Pediatric Simulation Training Karen M. Mathias, MSN, RN, APRN-BC Director Barbara J. Peterson, RN Simulation Specialist Objectives Identify key patient safety issues that make simulation
Medication Reconciliation with Pharmacy Technicians
Technician Education Day March 29, 2014 Jacksonville, FL Outline with Pharmacy Technicians Roma Merrick RPhT., CPhT. Pharmacy Technician Coordinator St. Vincent s Medical Center Southside Jacksonville,
The Human Factor: Applying Safety Science in Health Care
The Human Factor: Applying Safety Science in Health Care Sarah Henrickson Parker, PhD Director of Education and Academic Affairs, Research Scientist National Center for Human Factors Engineering in Healthcare
Never Events (Including Retained Foreign Objects) The Surgeons Point of View. J.H. Pat Patton, Jr., MD, FACS Henry Ford Hospital, Detroit, MI
Never Events (Including Retained Foreign Objects) The Surgeons Point of View J.H. Pat Patton, Jr., MD, FACS Henry Ford Hospital, Detroit, MI 1 Disclosures None 2 Learning Objectives Examine the occurrence,
Using Transparency to Drive Patient Safety
Session Code These presenter s have nothing to disclose Using Transparency to Drive Patient Safety Doug Salvador, MD MPH Chief Quality Officer, Baystate Health Chief Medical Officer, Baystate Medical Center
TIME OUT! A Patient Safety Strategy. Col Doug Risk, Lt Col Kelli Mack USAF Dental Evaluations & Consultation Service
TIME OUT! A Patient Safety Strategy Col Doug Risk, Lt Col Kelli Mack USAF Dental Evaluations & Consultation Service Disclosures The opinions expressed in this presentation are those of the authors and
Clinical Research Seminar
Clinical Research Seminar HOW TO DEVELOP A CORRECTIVE AND PREVENTIVE ACTION PLAN (THAT EVEN THE IRB AND FDA WILL LOVE) April 11, 2018 Fiona Rice, MPH Human Research Quality Manager fionar@bu.edu Mary-Tara
National Patient Safety Agency Root Cause Analysis (RCA) Investigation
National Patient Safety Agency Root Cause Analysis (RCA) Investigation Margaret O Donovan Assistant Director for Acute Services Types of failure Active failures - slips, lapses, fumbles, mistakes, procedural
Response to Safety Events Just Culture HR Policy 5.24 Page 1 of 10
Response to Safety Events Just Culture HR Policy 5.24 Page 1 of 10 Policy : 5.24 Subject: Supersedes: Effective: October 8, 2008 Revised: July 1, 2002, December 1, 2012 Reviewed: December 1, 2012 Response
Improving Safety Practices Anticoagulation Therapy
Improving Safety Practices Anticoagulation Therapy Katie Cinnamon, PharmD, BCPS Clinical Pharmacist Genesis Medical Center - Davenport Objectives Review background information on medication errors and
Patient Safety Overview
Patient Safety Overview Muhammad H. Islam, MBBS, MS, MCH, LSSBB Director of Patient Safety & Patient Safety Officer SUNY Downstate Medical Center, UHB www.downstate.edu/patientsafety Definitions Patient
ABMS Organizational QI Forum Links QI, Research and Policy Highlights of Keynote Speakers Presentations
ABMS Organizational QI Forum Links QI, Research and Policy Highlights of Keynote Speakers Presentations When quality improvement (QI) is done well, it can improve patient outcomes and inform public policy.
Understanding resilient clinical practice in Emergency Department ecosystems. Jeffrey Braithwaite, PhD Robyn Clay-Williams, PhD
Understanding resilient clinical practice in Emergency Department ecosystems Australian Institute of Health Innovation Jeffrey Braithwaite, PhD Robyn Clay-Williams, PhD Presentation to the Resilient Healthcare
THE AMERICAN BOARD OF PATHOLOGY PATIENT SAFETY COURSE APPLICATION
THE AMERICAN BOARD OF PATHOLOGY PATIENT SAFETY COURSE APPLICATION Requirements: Component I Patient Safety Self-Assessment Program Programs must meet the following criteria to be an ABP approved Patient
IMPACT OF TECHNOLOGY ON MEDICATION SAFETY
Continuous Quality Improvement IMPACT OF Steven R. Abel, PharmD, FASHP TECHNOLOGY ON Nital Patel, PharmD. MBA MEDICATION SAFETY Sheri Helms, PharmD Candidate Brian Heckman, PharmD Candidate Ismaila D Badjie
Achieving safety in medication management through barcoding technology
Achieving safety in medication management through barcoding technology Kara Marx, RN, FACHE, FHIMSS Vice President of Information Services Sharp Healthcare. SESSION OBJECTIVES Describe the primary activities
Journey to an Effective Safety Culture Part I of III Exploring the Role of Culture in Safety Outcomes. Embracing Patient Safety Culture
White Paper Journey to an Effective Safety Culture Part I of III Exploring the Role of Culture in Safety Outcomes Embracing Patient Safety Culture What is the Purpose of this Series? The purpose of this
Optimizing FMEA and RCA efforts in health care
PATIENT SAFETY Optimizing FMEA and RCA efforts in health care By Robert J. Latino INTRODUCTION Failure mode and effect analysis (FMEA) and root cause analysis (RCA) are becoming commonplace terms in work
Root Cause Analysis LITE (RCA Lite)
Root Cause Analysis LITE (RCA Lite) INTRODUCTION The root cause analysis Lite tool is designed to assist Ottawa Hospital teams to review an adverse event or near miss, identify root causes of the event
Patient Safety Initiatives of the VA National Center for Patient Safety
Patient Safety Initiatives of the VA National Center for Patient Safety At the Quality Colloquium at Harvard University John Gosbee, MD, MS August 27, 2003 National Center for Patient Safety Department
Assessing Medical Technology- Are We Being Told the Truth. The Case of CPOE. David C Classen M.D., M.S. FCG and University of Utah
Assessing Medical Technology- Are We Being Told the Truth. The Case of CPOE David C Classen M.D., M.S. FCG and University of Utah August 21, 2007 FCG 2006 Slide 1 November 2006 CPOE Adoption Growing Despite
How effective and sustainable are Root. HFESA Conference
How effective and sustainable are Root Cause Analysis (RCA) investigations 27 th November 2017 HFESA Conference Peter Hibbert, Matthew Thomas, Anita Deakin, Bill Runciman, Jeffrey Braithwaite Acknowledgements:
Yoder-Wise: Leading and Managing in Nursing, 5th Edition
Yoder-Wise: Leading and Managing in Nursing, 5th Edition Chapter 02: Patient Safety Test Bank MULTIPLE CHOICE 1. In an effort to control costs and maximize revenues, the Rehabilitation Unit at Cross Hospital
Emergency Management. High Risk/Low Frequency Emergencies Most high risk incidents do not happen very often (low frequency).
Emergency Management Generally speaking, a day spent working as a Security Professional is usually of a routine nature. After all, when was the last time you experienced a major emergency at work? You
Safe medication practice what can we learn from root cause analysis and related methods?
Safe medication practice what can we learn from root cause analysis and related methods? Dr David Gerrett, Senior Pharmacist Patient Safety NHS Improvement Information Day on Medication Errors 20 October
Breakfast With the Chiefs December 15, 2005 Philip Hassen, CEO, CPSI
Reflections: Ten Months and Where to From Here Breakfast With the Chiefs December 15, 2005 Philip Hassen, CEO, CPSI 1 Presentation Overview Nature of the Problem Safer Healthcare Now Campaign Systems vs.
Department of Defense INSTRUCTION. SUBJECT: Military Health System (MHS) Patient Safety Program (PSP) (MHSPSP)
Department of Defense INSTRUCTION NUMBER 6025.17 August 16, 2001 SUBJECT: Military Health System (MHS) Patient Safety Program (PSP) (MHSPSP) ASD(HA) References: (a) Sections 742 and 754 of the Floyd D.
Health Management Information Systems: Computerized Provider Order Entry
Health Management Information Systems: Computerized Provider Order Entry Lecture 2 Audio Transcript Slide 1 Welcome to Health Management Information Systems: Computerized Provider Order Entry. The component,
SOP:14:QA:110:01:NIBT PAGE 1 of 8
SOP:14:QA:110:01:NIBT PAGE 1 of 8 Northern Ireland Blood Transfusion Service STANDARD OPERATING PROCEDURE (Operational Copy) Document Details Document Number: SOP:14:QA:110:01:NIBT Supersedes Number: Not
Nicolas H. Malloy Systems Engineer
Integrating STAMP-Based Hazard Analysis with MIL-STD-882E Functional Hazard Analysis A Consistent and Coordinated Process Approach to MIL- STD-882E Functional Hazard Analysis Nicolas H. Malloy Systems
ABSTRACT. dose", all steps in the setup of the secondary infusion must be conducted correctly.
MITIGATING RISKS ASSOCIATED WITH SECONDARY INTRAVENOUS (IV) INFUSIONS: AN EMPIRICAL EVALUATION OF A TECHNOLOGY-BASED, A PRACTICE-BASED, AND A TRAINING-BASED INTERVENTION Katherine Y Chan 1,2, Sonia Pinkney
Reducing Medical Errors at the Bedside
Transcript Details This is a transcript of an educational program accessible on the ReachMD network. Details about the program and additional media formats for the program are accessible by visiting: https://reachmd.com/programs/clinicians-roundtable/reducing-medical-errors-at-the-bedside/3974/
Frontline Improvement Using Defect Analysis March 9, 2012 R Resar, MD; N Romanoff, MD, MPH; A Majka, MD; J Kautz, MD; D Kashiwagi, MD; K Luther, RN
Frontline Improvement Using Defect Analysis March 9, 2012 R Resar, MD; N Romanoff, MD, MPH; A Majka, MD; J Kautz, MD; D Kashiwagi, MD; K Luther, RN Introduction More than a decade ago, the Institute of
Refer to Appendix A for definitions of the terminology used throughout this policy.
Category: BOARD POLICY ADMINISTRATIVE PARAMETERS Title: Stop the Line : Authority to Intervene to Ensure Patient Safety Approved by: PHSA Board of Directors Reference Number: AS 130 Last Approved: June
Sharp HealthCare Safety Training 2015 Module 3, Lesson 2 Always Events: Line and Tube Reconciliation and Guardrails Use
Sharp HealthCare Safety Training 2015 Module 3, Lesson 2 Always Events: Line and Tube Reconciliation and Guardrails Use Our vision is to create a culture where patients and those who care for them are
How can the labelling and the packaging of drugs impact on drug safety? Prof. Pascal BONNABRY. Head of pharmacy. Swissmedic, Bern, June 19, 2007
How can the labelling and the packaging of drugs impact on drug safety? Head of pharmacy Swissmedic, To err is human (USA) Serious adverse events in 3% [2.9-3.7%] of hospitalizations 10% [8.8-13.6%] of
Creating High Reliability Organizations. Enhancing the Culture of Safety for Our Patients & Our Organizations
Creating High Reliability Organizations Enhancing the Culture of Safety for Our Patients & Our Organizations OUR TRUST by Dr. Don Berwick Reliability from the Patient s Perspective Don't kill me (no needless
Fostering a Culture of Safety
Fostering a Culture of Safety June 11, 2017 Alabama Society of Health System Pharmacists Presenter: Trey Gwin, RPh, MBA, Medication Safety Coordinator, Infirmary Health Financial Disclosure The speaker