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Med event committee confluence health
- 1. Confluence Health Med Event Committee WARNING: Every system is perfectly designed to get the results it produces.
- 3. Critical Thinking Skills? WARNING: Every system is perfectly designed to get the results it produces. 3
- 4. The Power of Incentives WARNING: Every system is perfectly designed to get the results it produces. 4
- 5. What happens when your stress level rises? WARNING: Every system is perfectly designed to get the results it produces. 5
- 6. Angel of Death and a Fair and Just Culture The Just Culture is an approach to dealing with human behavior that balances accountability with the recognition that humans can and will make mistakes. The Just Culture recognizes that we all have “duties” to perform, which can include the duty to follow a rule, the duty to produce an outcome or the duty to avoid harm. If we breach one of our duties, that behavior can be categorized in one of three ways: •Human Error: A lapse, a mistake, a slip, an accident. •At risk behavior: A behavioral choice that increases a risk, but that risk is either not recognized or is thought to be justified. •Reckless behavior: A behavioral choice that increases risk, despite the recognition of the increased risk. WARNING: Every system is perfectly designed to get the results it produces. 6
- 7. WARNING: Every system is perfectly designed to get the results it produces. 7
- 8. Mistake Proofing 1. Design for Minimum Hazard 2. Install Safety Devices 3. Use Safety Warnings 4. Control with Procedures / Administrative Controls 5. Personnel Action by Training, Awareness, Knowledge 6. Accepted Risk Effectiveness, reliability WARNING: Every system is perfectly designed to get the results it produces. 8
- 9. What Really Is A Near Miss WARNING: Every system is perfectly designed to get the results it produces. 9
- 10. Iceberg, Planes and Odd Training WARNING: Every system is perfectly designed to get the results it produces. 10
- 11. The Cost of Doing the Right Thing WARNING: Every system is perfectly designed to get the results it produces. 11
- 12. Entropy WARNING: Every system is perfectly designed to get the results it produces. 12 Thermal dynamics of Medication Errors and the argument For standard work
- 13. The Speed of Thought Your riding on your bike and you see this bin of apples fall of the truck in front of you. What is the first thing you do? No it wasn’t to swerve your bike it was that a bin of apples is falling off the truck. It is human nature To jump to a solution instead of analyzing the problem. WARNING: Every system is perfectly designed to get the results it produces. 13
- 14. Future We are ending this year and we have exceeded our wildest dreams preventing medication misadventures. What do you see in the crystal ball that made this happen? WARNING: Every system is perfectly designed to get the results it produces. 14