Dr. Ginette M. Collazo
|
|
- Gabriella Edwards
- 6 years ago
- Views:
Transcription
1 Human Error Reduction Model: Root Cause Determination, CAPA development and CAPA Effectiveness Measurement for Human Performance Related Deviations Dr. Ginette M. Collazo
2 Regulation Subpart B_Organization and Personnel Sec Responsibilities of quality control unit. (a) There shall be a quality control unit that shall have the responsibility and authority to approve or reject all components, drug product containers, closures, in-process materials, packaging material, labeling, and drug products, and the authority to review production records to assure that no errors have occurred or, if errors have occurred, that they have been fully investigated. The quality control unit shall be responsible for approving or rejecting drug products manufactured, processed, packed, or held under contract by another company.
3 What s coming?
4 High Reliable Organizations A High Reliability Organization (HRO) Succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity Chemical Nuclear Financial Aerospace We have learned what works and what does not.
5 How is Human Error controlled? 80% by using human factors in SYSTEMS (any aspect of the workplace or job implementation that makes it more likely for the worker to make an error) Management Systems 20% by managing acquired behaviors- PEOPLE We focus on systems and then people. We believe people make mistakes because they can. Our systems allow it.
6 What is happening? The 5 Errors Investigate technical problem not HE Real Root Cause is not identified IA/CA/PA Ineffective HE HE Human Error as a Root Cause Wrong problem is addressed We don t ask why. Root cause analysis for human error events is usually inexistent.
7 What can be done? THE METHOD
8 Diagnosis 12 Month Categorize & Code HE Rate Baseline Pulse Check Training Investigators Management Supervision and Operational Monitor/Trend Implement System Changes 80 Culture Change Process 20
9 Move away from human error creation. Break the Blame Cycle PPI, 2009
10 Will answer What How When Where Who Why? And then correct, prevent, predict and control.
11 Human error: but where? Strategic End User/Client Tactical Operational 11
12 Let s understand the 80% and the 20% System Problem Administrative Management Systems Human Error Human Performance Problem Operation Controls (factors) Individuals Work environment (external) Cognitive Overload (internal)
13 Administrative Management Systems 1. Policies & Administrative Controls 12 Root Causes 2. Quality and Risk Review- 5 Root Causes 3. Problem Identification, Investigation and Control- 4 Root Causes 4. Product/Material Control- 9 Root Causes 5. Procurement Control- 6 Root Causes 6. Documentation and Configuration Control- 7 Root Causes 7. Process/Validation/Project Planning- 9 Root Causes 8. Facilities/Maintenance- 5 Root Causes
14 Operation Controls 1. Procedures- 3 NRC= 22 RC 2. Human Factors Engineering- 4 NRC= 19 RC 3. Training- 3 NRC= 16 RC 4. Immediate Supervision- 2 NRC= 10 RC 5. Communication- 3 NRC=12 RC
15 Root Cause Wrong/Incomplete 33% 9% 14% 10% Typographical Sequence Facts wrong Wrong revision 12% 22% Inconsistency between requirements Incomplete
16 Individual Performance 1. Slip 2. Mistake 3. Violation Cognitive Load
17 Cognitive Load Available Time Stress Complexity and task design Experience/Trng. Instructions Human Machine Interphase Fitness for duty Work process/supervision Environment Communication
18 Tools
19 Cognitive Load Tool Software
20 Cognitive Load Tool- Graphic Results
21 CA-PA Effectiveness CA- Corrective PA- Preventive # of repeated events # of recurring root causes
22 Root Cause Determination Tool (RCDT)
23 Procedures Human Factors Engineering
24 RCDT SaaS
25 Root Cause
26 Results Baseline 4.7% Result 1.9% 60% Reduction in less than 10 months!!! 26
Business Safety Leadership. Part 2: Incident and Root Cause Analysis
Business Safety Leadership Part 2: Incident and Root Cause Analysis 1 Outline Importance of investigation process Incident reporting best practices 7 key steps of incident investigation Effective root
More informationBlood 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
More informationA 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
More informationTo Err is Human To Delay is Deadly Ten years later, a million lives lost, billions of dollars wasted
1999 Institute of Medicine study estimated that as many as 98,000 people die in any given year from medical errors that occur in hospitals. To Err is Human To Delay is Deadly Ten years later, a million
More informationEFFECTIVE ROOT CAUSE ANALYSIS AND CORRECTIVE ACTION PROCESS
I International Symposium Engineering Management And Competitiveness 2011 (EMC2011) June 24-25, 2011, Zrenjanin, Serbia EFFECTIVE ROOT CAUSE ANALYSIS AND CORRECTIVE ACTION PROCESS Branislav Tomić * Senior
More informationEnhancing 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
More informationMANAGEMENT OF PROTOCOL AND GCP DEVIATIONS AND VIOLATIONS
MANAGEMENT OF PROTOCOL AND GCP DEVIATIONS AND VIOLATIONS DOCUMENT NO.: CR010 v4.0 AUTHOR: Heather Charles ISSUE DATE: 01 September 2016 EFFECTIVE DATE: 15 September 2016 1 INTRODUCTION 1.1 The Academic
More informationMedical Device Reporting. FD&C Act CFR Direct Final Rule 2/28/05. As amended by:
Medical Device Reporting Direct Final Rule 2/28/05 FD&C Act 519 As amended by: Safe Medical Devices Act of 1990 Medical Device Amendments of 1992 FDA Modernization Act of 1997 Authority to require manufacturers,
More informationPatient Safety Case Study. Clara K. Terral. Angelo State University
Running Head: PATIENT SAFTEY CASE STUDY Patient Safety Case Study Clara K. Terral Angelo State University PATIENT SAFTEY CASE STUDY 2 The case study that stood out most to me was Case 18, which is Not
More informationGoals for this Training
Accident Investigation Training How to Conduct a Workplace Accident Investigation Emma Corell, Accident Prevention Manager EH&S, Research and Occupational Safety Goals for this Training Learn simple tools
More informationWashington Patient Safety Coalition December 10, 2014
Innovating the RCA: Root Cause Analysis & Just Culture Washington Patient Safety Coalition December 10, 2014 Andrea Halliday, MD Interim Patient Safety Officer, PeaceHealth David Allison, CPHRM Interim
More informationHigh Reliability Organizations Healing Without Harm by 2014
Please click your mouse or use the enter button to move onto the next slide High Reliability Organizations Healing Without Harm by 2014 1.1 Stand up if You have suffered harm as a patient at a hospital
More informationChapter 2 Nursing Process
Chapter 2 Nursing Process Definition of the Nursing Process Organized sequence of problem-solving steps Used to identify and manage the health problems of clients Accepted standard for clinical practice:
More informationHigh Reliability Organizations The Key to Improving Quality and Safety
High Reliability Organizations The Key to Improving Quality and Safety William B Munier, MD, MBA Acting Director Center for Quality Improvement and Patient Safety Agency for Healthcare Research and Quality
More informationJust 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
More informationComponent Description Unit Topics 1. Introduction to Healthcare and Public Health in the U.S. 2. The Culture of Healthcare
Component Description (Each certification track is tailored for the exam and will only include certain components and units and you can find these on your suggested schedules) 1. Introduction to Healthcare
More informationAAPM Responds to Follow up Questions from Congress after Hearing on Radiation in Medicine
AAPM Responds to Follow up Questions from Congress after Hearing on Radiation in Medicine Table of Contents Letter from the Congressman Henry A. Waxman, Chairman of the House of Representatives Committee
More informationA QUANTITATIVE ACQUISITION PROCESS MODELING APPROACH TOWARD EXPEDITING SYSTEMS ENGINEERING Yvette Rodriguez
A QUANTITATIVE ACQUISITION PROCESS MODELING APPROACH TOWARD EXPEDITING SYSTEMS ENGINEERING Yvette Rodriguez 06 April 2017 USC Center for Systems and Software Engineering 2017 Annual Research Review Research
More informationCreating 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
More informationSHRI GURU RAM RAI INSTITUTE OF TECHNOLOGY AND SCIENCE MEDICATION ERRORS
MEDICATION ERRORS Patients depend on health systems and health professionals to help them stay healthy. As a result, frequently patients receive drug therapy with the belief that these medications will
More informationBrachytherapy-Radiopharmaceutical Therapy Quality Management Program. Rev Date: Feb
Section I outlines definitions, reporting, auditing and general requirements of the QMP program while Section II describes the QMP implementation for each therapeutic modality. Recommendations are expressed
More informationINCIDENT INVESTIGATION
Carson, CA Inland Star Distribution Centers, Inc. Incident Investigation INCIDENT INVESTIGATION Revision History Rev. # Description of Change Date Revised By 0 Initial Issue July 2016 PSM RMP Solutions
More informationUnderstanding 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)
More informationINCIDENT INVESTIGATION PROGRAM
INCIDENT INVESTIGATION PROGRAM 1.0 PURPOSE The purpose of this program is to prevent the recurrence of an incident and to eliminate or minimize the risks associated with the incident. 2.0 SCOPE This procedure
More informationThe 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
More informationSJN DO CB Field Alert Reports. Edwin Ramos Director of Compliance Food and Drug Administration San Juan District Office
SJN DO CB Field Alert Reports Edwin Ramos Director of Compliance Food and Drug Administration San Juan District Office SJN DO Mission Assuring that safe and effective drugs are available to the public
More informationThe ABR MOC Part IV:
The ABR MOC Part IV: Practice Quality Improvement (PQI) Stephen R. Thomas, Ph.D ABR Associate Executive Director Radiologic Physics (RP) The ABR Radiologic Physics Trustees Richard L. Morin, Ph.D. Diagnostic
More informationAdministrative Policies and Procedures. Policy No.: N/A Title: Medical Equipment Management Plan
Administrative Policies and Procedures Originating Venue: Environment of Care Title: Medical Equipment Management Plan Cross Reference: Date Issued: 11/14 Date Reviewed: Date: Revised: Attachment: Page
More informationReport on Feasibility, Costs, and Potential Benefits of Scaling the Military Acuity Model
Report on Feasibility, Costs, and Potential Benefits of Scaling the Military Acuity Model June 2017 Requested by: House Report 114-139, page 280, which accompanies H.R. 2685, the Department of Defense
More informationQUALITY ASSURANCE PROGRAM STANDARD. (Basic Requirements: JIS Q 9100)
QUALITY ASSURANCE PROGRAM STANDARD (Basic Requirements: JIS Q 9100) November 27, 2015 Japan Aerospace Exploration Agency The official version of this standard is written in Japanese. This English version
More informationComplaints Investigation and Review. Dr. Ademola Daramola International Relations Specialist Drugs US FDA India Office New Delhi February 22nd 2018
Complaints Investigation and Review Dr. Ademola Daramola International Relations Specialist Drugs US FDA India Office New Delhi February 22nd 2018 Information presented in this presentation does not represent
More informationSheriff s Office High Risk Equipment and Supplies Management Audit
AUDITOR GREG KIMSEY Sheriff s Office High Risk Equipment and Supplies Management Audit Clark County Auditor s Office Report #15-02 August 20, 2015 Audit Services 1300 Franklin Street, Suite 575, P.O. Box
More informationSAN JOAQUIN VALLEY UNIFIED AIR POLLUTION CONTROL DISTRICT COMPLIANCE DEPARTMENT COM 2035
SAN JOAQUIN VALLEY UNIFIED AIR POLLUTION CONTROL DISTRICT COMPLIANCE DEPARTMENT COM 2035 APPROVED: DATE: January 23, 2013 Morgan Lambert Director of Compliance TITLE: SUBJECT: RULE 1100 EQUIPMENT BREAKDOWN
More informationADMINISTRATIVE POLICY & PROCEDURE PATIENT SAFETY PLAN
PAGE #: 1 of 6 CROSS REFERENCES: Administrative Policy PI-01: Administrative Policy PI-03: Administrative Policy RI-20: Administrative Policy EC-25: Sentinel Event Risk Management Plan Guidelines for Disclosure
More informationRegulatory,Quality & Emergency Preparedness. MaryBeth Parache Director, Quality Affairs New York Blood Center
Regulatory,Quality & Emergency Preparedness MaryBeth Parache Director, Quality Affairs New York Blood Center 1 Regulatory 2 Who regulates us? Food and Drug Administration (FDA) Blood, tissue, HCT/P, medical
More informationAccident/Incident Investigation Plan
South Central College North Mankato/Mankato Campus 1920 Lee Boulevard N. Mankato, MN 56002-1920 Faribault Campus 1225 Third Street SW Faribault, MN 55021-5782 Adoption Date: 07-08-15 Revision Date: 12-29-16
More informationIncidents reported to MERU, HSE in Diagnostic Radiology (including Nuclear Medicine) and in Radiotherapy The MERU, HSE (2013)
Incidents reported to MERU, HSE in Diagnostic Radiology (including Nuclear Medicine) and in Radiotherapy 2010-2012 The MERU, HSE (2013) CONTENT Executive summary.. 2 Introduction 3 Incidents reported in
More informationMARYLAND RADIOLOGICAL HEALTH PROGRAM UPDATE
Maryland Department of the Environment MARYLAND RADIOLOGICAL HEALTH PROGRAM UPDATE PRESENTED BY ROLAND G. FLETCHER, PROGRAM MANAGER IV AT THE MID ATLANTIC STATES RADIATION PROTECTION CONFERENCE THE DESMOND
More informationGuide for the Incident Investigation Form (Incident Investigation Report)
Please refer to the companion Incident Investigation Quick Guide for assistance completing the investigation and this form. Employer s information Employer s name Employer s head office address City Province
More informationDepartment of Defense DIRECTIVE
Department of Defense DIRECTIVE NUMBER 3150.2 December 23, 1996 Certified Current as of March 8, 2004 SUBJECT: DoD Nuclear Weapon System Safety Program ATSD(NCB) References: (a) DoD Directive 3150.2, "Safety
More informationDepartment of Defense DIRECTIVE
Department of Defense DIRECTIVE NUMBER 4540.5 February 4, 1998 ATSD(NCB) SUBJECT: Logistic Transportation of Nuclear Weapons References: (a) DoD Directive 4540.5, "Movement of Nuclear Weapons by Noncombat
More informationCMMI: The DoD Perspective
Sponsored by the U.S. Department of Defense 2006 by Carnegie Mellon University CMMI: The DoD Perspective Rick Barbour Chief Engineer Navy, Acquisition Support Program page 1 Acknowledgement Presentation
More informationTIME 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
More informationLegal Medical Institute. Introduction to Nurse Paralegal
Legal Medical Institute Introduction to Nurse Paralegal Legal Medical Institute brightoncollege.edu 800-354-1254 8777 E. Via de Ventura, Scottsdale, AZ 85258 Accredited What Are Nurse Paralegals? A nurse
More informationNAVSEA STANDARD ITEM CFR Part 61, National Emission Standards for Hazardous Air Pollutants
NAVSEA STANDARD ITEM ITEM NO: 009-01 DATE: 01 OCT 2017 CATEGORY: I 1. SCOPE: 1.1 Title: General Criteria; accomplish 2. REFERENCES: 2.1 Standard Items 2.2 40 CFR Part 61, National Emission Standards for
More informationStrategies for Good Communication of the Medical Laboratory Staff with the TB Program and Healthcare Providers
Strategies for Good Communication of the Medical Laboratory Staff with the TB Program and Healthcare Providers Vasiti Uluiviti Regional Laboratory Coordinator PIHOA 2017 PITCA Meeting Sept 11 th 15 th
More informationJune 2018 Phc newsletter
June 2018 Phc newsletter News from CMS and Joint Commission Inside This Issue: ü Perspectives Leadership Session Be Prepared for Changes SAFER Matrix Placement Under Review - # RFIs Still Important Not
More informationF 35 Lightning II Program Quality Assurance and Corrective Action Evaluation
Report No. DODIG-2015-092 I nspec tor Ge ne ral U.S. Department of Defense MARCH 11, 2015 F 35 Lightning II Program Quality Assurance and Corrective Action Evaluation I N T E G R I T Y E F F I C I E N
More informationSafety Management Functions, Responsibilities and Authorities Manual (FRAM) Revision 1
Safety Management Functions, Responsibilities and Authorities Manual (FRAM) Revision 1 DISTRIBUTION: All NNSA Revision INITIATED BY: Office of Operations and Construction Management Military Application
More informationNAVSEA STANDARD ITEM CFR Part 61, National Emission Standards for Hazardous Air Pollutants
NAVSEA STANDARD ITEM ITEM NO: 009-01 DATE: 18 JUL 2014 CATEGORY: I 1. SCOPE: 1.1 Title: General Criteria; accomplish 2. REFERENCES: 2.1 40 CFR Part 61, National Emission Standards for Hazardous Air Pollutants
More informationSummary Report for Individual Task H-3527 Determine Compatibility of Dangerous or Hazardous Cargo Status: Approved
Report Date: 26 Mar 2014 Summary Report for Individual Task 551-88H-3527 Determine Compatibility of Dangerous or Hazardous Cargo Status: Approved DISTRIBUTION RESTRICTION: Approved for public release;
More informationAGGRESSIVE BEHAVIOR TOOLKIT WSHA & ASHNHA PARTNERSHIP FOR PATIENTS PRESENTED BY: COURTNEY ULRICH
AGGRESSIVE BEHAVIOR TOOLKIT WSHA & ASHNHA PARTNERSHIP FOR PATIENTS PRESENTED BY: COURTNEY ULRICH HIIN AND PARTNERSHIP FOR PATIENTS The Partnership for Patients initiative is a public-private partnership
More informationSFHPHARM11 - SQA Unit Code FA2X 04 Prepare extemporaneous medicines for individual use
Prepare extemporaneous medicines for individual use Overview This standard covers your role in preparing extemporaneous medicines for individual use. This involves accurately calculating the quantities
More informationFostering 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
More informationHuman Samples in Research
Human Samples in Research Adverse Event Reporting Document Identifier HTA-11-SOP-Adverse Event Reporting AUTHOR APPROVER EFFECTIVE DATE: Name and role Signature and date Name and role Signature and date
More informationUNCLASSIFIED. UNCLASSIFIED Air Force Page 1 of 7 R-1 Line #91
Exhibit R-2, RDT&E Budget Item Justification: PB 2015 Air Force : March 2014 3600: Research, Development, Test & Evaluation, Air Force / BA 5: Development & Demonstration (SDD) COST ($ in Millions) # FY
More informationDepartment of Defense
1Gp o... *.'...... OFFICE O THE N CTONT GNR...%. :........ -.,.. -...,...,...;...*.:..>*.. o.:..... AUDITS OF THE AIRFCEN AVIGATION SYSEMEA FUNCTIONAL AND PHYSICAL CONFIGURATION TIME AND RANGING GLOBAL
More informationVERIFICATION OF READINESS TO START UP OR RESTART NUCLEAR FACILITIES
ORDER DOE O 425.1D Approved: VERIFICATION OF READINESS TO START UP OR RESTART NUCLEAR FACILITIES U.S. DEPARTMENT OF ENERGY Office of Health, Safety and Security DOE O 425.1D 1 VERIFICATION OF READINESS
More informationThe Newcastle upon Tyne Hospitals NHS Foundation Trust
The Newcastle upon Tyne Hospitals NHS Foundation Trust Incidents, Accidents and the Trust Disciplinary Process - Guidelines for Managers, Clinical Directors and Employees Version.: 4.1 Effective From:
More informationCertified Healthcare Safety Long Term Care (CHS-LTC) Examination Blueprint/Outline
Certified Healthcare Safety Long Term Care (CHS-LTC) Examination Blueprint/Outline Exam Domains 100-130 1. Safety Management Principles 31-40 (31%) 2. Hazard Control Concepts 46-60 (46%) 3. Compliance
More informationSusan Moffatt-Bruce, MD, PhD Chief Quality and Patient Safety Officer Associate Professor of Surgery The Ohio State University s Wexner Medical Center
Engaging the team: Steps to Reduce Complications Susan Moffatt-Bruce, MD, PhD Chief Quality and Patient Safety Officer Associate Professor of Surgery The Ohio State University s Wexner Medical Center Safety
More informationMEETING THE CHALLENGE OF BURNOUT. Christina Maslach, Ph.D. University of California, Berkeley
MEETING THE CHALLENGE OF BURNOUT Christina Maslach, Ph.D. University of California, Berkeley BURNOUT AMONG HEALTH CARE PROFESSIONALS Health care has been the primary occupation for research on burnout,
More informationPreventing 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.
More informationPatient 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
More informationRequest for Offer (RFO) # Change Management Requirements
Request for Offer (RFO) # 12-4769 Change Management Requirements For: CALREACH You are invited to review and respond to this RFO. To submit an offer for these goods and/or services, you must comply with
More information2016 Experian Information Solutions, Inc. All rights reserved. Experian and the marks used herein are service marks or registered trademarks of
2016 Experian Information Solutions, Inc. All rights reserved. Experian and the marks used herein are service marks or registered trademarks of Experian Information Solutions, Inc. Other product and company
More informationCertified Healthcare Safety Environmental Services (CHS-EVS) Examination Blueprint/Outline
Certified Healthcare Safety Environmental Services (CHS-EVS) Examination Blueprint/Outline Exam Domains 100-130 1. Safety Management 38-50 (38%) 2. Hazard Control 38-50 (38%) 3. Compliance & Voluntary
More informationEPSC s activities are directed towards four principal objectives:
BENCHMARKING ON EPSC MEMBER COMPANY INCIDENT REPORTING SYSTEMS Simon Jones, Manager EPSC Operations 165-179 Railway Terrace, Rugby, CV21 3HQ, UK SUMMARY The European Process Safety Centre (EPSC) has carried
More information9/9/2016. 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
More informationSelf Assessment Guide for an Effective Safety and Health Program
Self Assessment Guide for an Effective Safety and Health Program The revised Rural Electric Safety Achievement Program provides the frame work for cooperatives to develop safety and health programs that
More informationU-M Hospitals and Health Centers Policies and Procedures
U-M Hospitals and Health Centers Policies and Procedures UMHHC Policy 05-02-006 Safe Medical Device Act Policy Issued: 4/00; Last Reviewed: 10/04; Last Revised: 10/04 Return to UMHHC Policies Table of
More informationLetitia 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.
More information5. Effective Date: See the Implementation Plan for IRO B. Requirements and Measures
A. Introduction 1. Title: Reliability Coordinator Actions to Operate Within IROLs 2. Number: IRO-009-2 3. Purpose: To prevent instability, uncontrolled separation, or cascading outages that adversely impact
More informationRoot 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
More informationHRO and Dx. High Reliability and Diagnosis. Mark Graber and Michael Crossey. Panel 1 // March 6, 2014 // 2:30-3:45 pm 7/2/2014
HRO and Dx Mark Graber and Michael Crossey High Reliability and Diagnosis Panel 1 // March 6, 2014 // 2:30-3:45 pm Attaining High Reliability and Safety for Patients Collaborating for Change. Patient Safety
More information2018 Institutional Support of Research and Creativity (ISRC) and Teaching and Learning with Technology (TLT) Grants Program
2018 Institutional Support of Research and Creativity (ISRC) and Teaching and Learning with Technology (TLT) Grants Program The New York Institute of Technology (NYIT) invites faculty to apply to the ISRC
More informationAbout Humanscale Healthcare
Healthier by Design About Humanscale Healthcare We create next generation medication administration carts, mobile workstations, wall mounts, seating and accessories all specifically designed for the healthcare
More informationSCHOOLS INCIDENT REPORTING, RECORDING and INVESTIGATION
SCHOOLS INCIDENT REPORTING, RECORDING and INVESTIGATION Page 1 of 14 Amendment Register Revision Number Date Details Amended By Approved By Page 2 of 14 Contents Page Number 1. Introduction 4 2. Scope
More informationPatient Safety. Annual Accidental Deaths. Medical Errors in History. How Hazardous Is Health Care (Amalberti)
Patient Safety Annual Accidental Deaths 100000 90000 80000 70000 60000 50000 40000 30000 20000 10000 0 Medical Auto Workplace Air Deaths Total lives lost per year How Hazardous Is Health Care (Amalberti)
More informationTo detail the context, purpose and expectations related to Health, Safety and Wellbeing processes relating to the RMIT Community.
1.0 Objective To detail the context, purpose and expectations related to Health, Safety and Wellbeing processes relating to the RMIT Community. By actively aligning with the requirements and expectations
More informationUSEPA Chemical Accident Prevention Inspection and Enforcement Processes
USEPA Chemical Accident Prevention Inspection and Enforcement Processes EPA Risk Management Inspection Processes Summary of Region 9 Risk Management Program General Duty Clause EPA Region 9 Inspections
More information2. Why Applying Human Factors Is Important For Patient Safety
PATIENT SAFETY 436 TEAM 2. Why Applying Human Factors Is Important For Patient Safety Objectives: Understand Human Factors And Its Relationship To Patient Safety Define The Meaning Of The Term Human Factors
More informationCreating 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
More informationRadiation Licensure and Management (RS100) Course
Intro/Opening Welcome to the Radiation Licensure and Management course. This training is designed and required for anyone who is requesting a Radiation License at UAB. The intent of this course is to inform
More informationIHI Expedition. Engaging Frontline Teams to Create a Culture of Safety. March 14 th, Annette Bartley, RN, MS, MPH Tracy Jacobs, BSN, RN
March 14 th, 2013 These presenters have nothing to disclose IHI Expedition Engaging Frontline Teams to Create a Culture of Safety Annette Bartley, RN, MS, MPH Tracy Jacobs, BSN, RN Today s Host 2 Lizzie
More informationNACRS Data Elements
NACRS s 08 09 The following table is a comparative list of NACRS mandatory and optional data elements for all data submission options, along with a brief description of the data element. For a full description
More informationRULES OF THE TENNESSEE DEPARTMENT OF INTELLECTUAL AND DEVELOPMENTAL DISABILITIES OFFICE OF LICENSURE
RULES OF THE TENNESSEE DEPARTMENT OF INTELLECTUAL AND DEVELOPMENTAL DISABILITIES OFFICE OF LICENSURE CHAPTER 0465-02-17 MINIMUM PROGRAM REQUIREMENTS FOR INTELLECTUAL AND DEVELOPMENTAL DISABILITIES PERSONAL
More informationConduct Field Maintenance on a Hydra-start System Status: Approved
Report Date: 03 Oct 2016 551-881-8211 Conduct Field Maintenance on a Hydra-start System Status: Approved Distribution Restriction: Approved for public release; distribution is unlimited. Destruction tice:
More informationWhat 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
More informationEmbracing a Culture of Safety and Learning
Embracing a Culture of Safety and Learning Provincial Forum on Adverse Health Event Management St. John s Newfoundland May 26, 2008 Ward Flemons MD, FRCPC Vice-President, Health Outcomes Outline Adverse
More informationOpen DFARS Cases as of 5/10/2018 2:29:59PM
Open DFARS Cases as of 2:29:59PM 2018-D032 215 (R) Repeal of DFARS clause "Pricing Adjustments" 2018-D031 231 (R) Repeal of DFARS clause "Supplemental Cost Principles" 2018-D030 216 (R) Repeal of DFARS
More informationAssessment of the DSE 40mm Grenades
Report No. DODIG-2013-122 I nspec tor Ge ne ral Department of Defense AUGUST 22, 2013 Assessment of the DSE 40mm Grenades I N T E G R I T Y E F F I C I E N C Y A C C O U N TA B I L I T Y E X C E L L E
More informationNumber: DI-MGMT Approval Date:
DATA ITEM DESCRIPTION Title: Technical Data Report Number: DI-MGMT-82165 Approval Date: 20171116 AMSC Number: 9871 Limitation: DTIC Applicable: No GIDEP Applicable: No Preparing Activity: CAPE Project
More information2017 Procure-to-Pay Training Symposium 2
DEFENSE PROCUREMENT AND ACQUISITION POLICY PROCURE-TO-PAY TRAINING SYMPOSIUM Reporting Grants and Cooperative Agreements to DAADS Presented by: Jovanka Caton Brian Davidson May 30 June 1, 2017 Hyatt Regency
More informationI. Summary. Commercial operation commencement date April , February , June ,
I. Summary 1. Overview of the Reviewed Power Station The Japan Nuclear Technology Institute (JANTI) conducted a peer review (review) at Fukushima Daini Nuclear Power Station (station) of Tokyo Electric
More informationDepartment of Defense DIRECTIVE. SUBJECT: Standardization of Mobile Electric Power (MEP) Generating Sources
Department of Defense DIRECTIVE NUMBER 4120.11 April 13, 2004 SUBJECT: Standardization of Mobile Electric Power (MEP) Generating Sources ASD(P&L) References: (a) DoD Directive 4120.11, "Standardization
More informationSpring Quarter, 2014, 4 credits for ENVH 560 / 3 Credits for ENVH 460, 11 weeks
Course Syllabus ENVH 460/560 Occupational Safety Management Canvas.uw.edu Spring Quarter, 2014, 4 credits for ENVH 560 / 3 Credits for ENVH 460, 11 weeks Time: Tuesday, 10:30 1:20 pm (ENVH 460) 10:30-2:20
More informationEnd-to-end infusion safety. Safely manage infusions from order to administration
End-to-end infusion safety Safely manage infusions from order to administration New demands and concerns 56% 7% of medication errors are IV-related. 1 of high-risk IVs are compounded in error. 2 $3.5B
More informationCWE TM COMPATIBILITY ENFORCEMENT
CWE TM COMPATIBILITY ENFORCEMENT AUTOMATED SOURCE CODE ANALYSIS TO ENFORCE CWE COMPATIBILITY STREAMLINE CWE COMPATIBILITY ENFORCEMENT The Common Weakness Enumeration (CWE) compatibility enforcement module
More informationLa Crosse Area Safety Council. La Crosse, Wisconsin October 24, 2016
La Crosse Area Safety Council La Crosse, Wisconsin October 24, 2016 Your presenter Leslie Ptak Industrial Hygienist Compliance Assistance Specialist, Madison OSHA office Ptak.Leslie@dol.gov 608-441-5388
More information