Module 2: The essentials: Principles, concepts and leading practices
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The essential components of effective, credible and reliable incident analysis and management will be explored during this module. A good understanding of the principles, concepts and leading practices is fundamental because organizations need to nurture and support their use on an ongoing basis. Practical examples and facilitated discussions will help participants bridge this knowledge with their practice.
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Module 2: The essentials: Principles, concepts and leading practices
- 1. Incident Analysis Learning Program - Module Two The Essentials: Principles, Concepts and Leading Practices Thursday, November 29, 2012
- 2. Welcome Ioana Popescu Sandi Kossey Carrie-Lynn Haines Tina Cullimore
- 3. Learning Objectives Understand the following: • Principles: safe and just culture; consistency and fairness; team approach; confidentiality • Concepts: Swiss cheese model; systems thinking ; human factors; complexity; sphere of influence; systems level; bias Ability to: • Differentiate between a just culture and a culture that is “blame and shame” • Discuss and describe the difference(s) between person thinking and system thinking • Describe how human factors is utilized to improve reliability and safety. • Describe one method to overcome bias using a personal example.
- 4. Agenda 1. Case study 2. Theory 3. Small group discussion
- 5. The Virtual Meeting Room Be prepared to use: • Text tool for annotations • Q&A and chat for questions • Emoticons for interactions 5 6-Dec-12 5
- 6. Where are you from? Click on “T” click on the map type X International: (type here)
- 7. About You 0 Familiarity with incident analysis / management 10 0 Familiarity with the Canadian Incident Analysis Framework 10
- 8. Part 1: Case Study Melissa Griffin, University Health Network
- 10. Components Used to Deliver Medication http://www.ismp-canada.org/download/reports/FluorouracilIncidentMay2007.pdf
- 13. Calculation 5250 mg / 4 days = 1312.5 mg /day 1312.5 mg / 24 hours = 54.69 mg / hour 54.69 mg / hour divided by 45.57 mg / mL = 1.2 mL / h = 28.8 mL / h http://www.ismp-canada.org/download/reports/FluorouracilIncidentMay2007.pdf
- 15. Video
- 16. Culture Shift
- 17. Q&A
- 18. Part 2: Theory Burst - Principles Jennifer White, Saskatchewan Ministry of Health
- 21. Safe and Just Culture “ To promote a culture in which we learn from our mistakes, organizations must re-evaluate just how their disciplinary system fits into the equation. Disciplining employees in response to honest mistakes does little to improve the overall system safety.” David Marx
- 23. Team Approach
- 24. Confidentiality
- 25. Theory Burst - Concepts
- 27. Systems Thinking and Human Factors “Clearly certain structure is needed; and equally clearly, there is no way to change outcome except through changing process, since outcome ‘tells on’ process.” VN Slee et al. (1996).
- 28. Systems Thinking and Human Factors Human factors is a discipline dedicated to uncovering and addressing disconnect between: • People • Tools and Technology • Environment When people use tools and work in environments that do not support them, errors or near misses can occur.
- 31. Incidental Incidental Finding Actionable Finding Factor Factor Factor Factor Actionable Factor Factor Factor Factor Factor Factor Task Other Factor Factor System Equipment Actionable Factor Factor Incident: Outcome: Work Environment Organization Factor Factor Actionable Patient Factor Factor Care Team Factor Incidental Factor Finding Factor Factor Factor Factor Factor Actionable Factor Actionable Incidental Actionable Actionable Actionable Factor Finding Factor Factor Factor
- 32. Systems Levels
- 33. Context
- 34. Leading Practices Features Timely Interdisciplinary Objective, impartial Credible LEARN Thorough Those associated with the Detail incident Analysis Leadership Recommended actions Information Documentation Evaluation plan Follow-through
- 35. Cognitive Traps Types of cognitive bias affecting outcome of an analysis: • Oversimplification • Overestimation • Overrating • Misjudging • Premature completion • Overconfidence
- 36. Cognitive Traps How bias can contribute to a patient safety incident: • Confirmation Bias • Inattention Bias
- 37. Q&A
- 38. Part 3: Applied Learning
- 39. Breakout Session Most participants will “move” to breakout rooms Some participants will stay in the main room Those prompted: click YES to both pop-up screens to “move”
- 40. Current Status Just culture Consistency, fairness Team approach Confidentiality Systems thinking (levels, context, influence) Human factors
- 41. Discuss: barriers - solutions
- 42. Write a goal “Tomorrow I/we will….”
- 43. Report Back
- 45. Wrap-up
- 46. Next Steps • End of session evaluation certificate • Follow up survey we learn from you Incident Analysis Learning Program • Incident analysis as part of the incident management continuum – December 13, 2012 • Comprehensive analysis – January 10, 2013 • Concise analysis – January 31, 2013 • Multi-incident analysis – February 21, 2013 • Recommendations management – March 7, 2013 • Follow-through and share what was learned – March 28, 2013
- 47. Additional Resources Fluorouracil Incident Root Cause Analysis - ISMP Canada Incident Analysis and Management - Tools – a collection of documents, templates, guidelines, and examples Recordings/ slides: previous modules and info call Contact us at: analysis@cpsi-icsp.ca
- 48. Mulţumesc Thank You
- 49. Just in case slides
- 50. Principles
- 51. Concepts
- 52. Leading Practices Features Timely Interdisciplinary Objective, impartial Credible LEARN Thorough Those associated with the Detail incident Analysis Leadership Recommended actions Information Documentation Evaluation plan Follow-through