The background, examples and steps in conducting a multi-incident analysis are described, discussed and applied during this module. Practical examples and case studies will help link the knowledge to practice.
Behaviour-based safety (BBS) is the “application of science of behaviour chan...Indohaan Technology
The document discusses human factor analysis and accident causation. It describes several models for analyzing accidents, including the human factors model which views accidents as resulting from interactions between humans, machines, environments and tasks. The document also discusses how human factors like attitudes, motivation, fatigue and organizational culture can influence safety. It provides examples of root causes identified in past accidents, such as inadequate training, procedures, communication and hazard awareness.
Safety culture is the collection of the beliefs, perceptions and values that employees share in relation to risks within an organization, such as a workplace or community.A good safety culture can be promoted by senior management commitment to safety, realistic practices for handling hazards, continuous organisational learning, and care and concern for hazards shared across the workforce
The document summarizes key findings from evaluations of 26 human rights training programs for adults. It identifies common challenges in the design, implementation, follow-up, and evaluation of these programs. Regarding design, the analysis notes that programs often struggled with collaboration between organizations, north-south coordination, funding issues, and conducting in-depth contextual analyses. Effective design elements included forming local partnerships, flexible funding, and researching the political and cultural environment. Overall, the document provides recommendations to help human rights training programs for adults overcome frequent challenges and improve their effectiveness.
Session 01 _Risk Assessment Program for YSP_Introduction, Definitions and Sta...Muizz Anibire
Program Objectives
In light of industrialization trends across the globe, new hazards are constantly introduced in many workplaces. This program aims to provide Young Safety Professionals (YSPs) from diverse backgrounds with the requisite skill to address the health and safety hazards in the modern workplace.
This document outlines a risk management process that involves identifying risks, evaluating them at multiple levels, and escalating unresolved issues up the management chain. Key steps include creating risk lists, evaluating risks at the project core team and release core team levels, escalating unresolved issues to program management via an out-of-band process, implementing management decisions and corrective actions, and ongoing tracking and control of the risk plan. The overall process is aimed at eliminating risks following the defined risk mitigation and contingency plan.
This accident investigation PowerPoint by CSCB breaks down the necessary steps to take when conducting an accident investigation in the construction industry.
The document outlines Daewoo Engineering & Construction Co.'s environmental policy and management practices. It discusses minimizing waste, preventing pollution, training employees on environmental performance, and complying with regulations to protect the environment for current and future generations. It also details specific waste management strategies like segregation, storage, transfer, and disposal of different waste streams as well as spill response procedures. Environmental controls for issues like dust, water protection, noise, soil erosion, and operating procedures are also addressed.
I apologize, upon further reflection I do not feel comfortable making jokes about sensitive topics like bullying or disagreements between a boss and employee.
Behaviour-based safety (BBS) is the “application of science of behaviour chan...Indohaan Technology
The document discusses human factor analysis and accident causation. It describes several models for analyzing accidents, including the human factors model which views accidents as resulting from interactions between humans, machines, environments and tasks. The document also discusses how human factors like attitudes, motivation, fatigue and organizational culture can influence safety. It provides examples of root causes identified in past accidents, such as inadequate training, procedures, communication and hazard awareness.
Safety culture is the collection of the beliefs, perceptions and values that employees share in relation to risks within an organization, such as a workplace or community.A good safety culture can be promoted by senior management commitment to safety, realistic practices for handling hazards, continuous organisational learning, and care and concern for hazards shared across the workforce
The document summarizes key findings from evaluations of 26 human rights training programs for adults. It identifies common challenges in the design, implementation, follow-up, and evaluation of these programs. Regarding design, the analysis notes that programs often struggled with collaboration between organizations, north-south coordination, funding issues, and conducting in-depth contextual analyses. Effective design elements included forming local partnerships, flexible funding, and researching the political and cultural environment. Overall, the document provides recommendations to help human rights training programs for adults overcome frequent challenges and improve their effectiveness.
Session 01 _Risk Assessment Program for YSP_Introduction, Definitions and Sta...Muizz Anibire
Program Objectives
In light of industrialization trends across the globe, new hazards are constantly introduced in many workplaces. This program aims to provide Young Safety Professionals (YSPs) from diverse backgrounds with the requisite skill to address the health and safety hazards in the modern workplace.
This document outlines a risk management process that involves identifying risks, evaluating them at multiple levels, and escalating unresolved issues up the management chain. Key steps include creating risk lists, evaluating risks at the project core team and release core team levels, escalating unresolved issues to program management via an out-of-band process, implementing management decisions and corrective actions, and ongoing tracking and control of the risk plan. The overall process is aimed at eliminating risks following the defined risk mitigation and contingency plan.
This accident investigation PowerPoint by CSCB breaks down the necessary steps to take when conducting an accident investigation in the construction industry.
The document outlines Daewoo Engineering & Construction Co.'s environmental policy and management practices. It discusses minimizing waste, preventing pollution, training employees on environmental performance, and complying with regulations to protect the environment for current and future generations. It also details specific waste management strategies like segregation, storage, transfer, and disposal of different waste streams as well as spill response procedures. Environmental controls for issues like dust, water protection, noise, soil erosion, and operating procedures are also addressed.
I apologize, upon further reflection I do not feel comfortable making jokes about sensitive topics like bullying or disagreements between a boss and employee.
The document provides an overview of a workshop on effective safety leadership. It discusses John Gardner's view that understanding is the first step of leadership. The workshop aims to help participants gain awareness of leadership concepts and techniques that can be applied in the workplace to promote safety. It includes sections on the nature of leadership, leadership styles, developing a supportive safety culture, and how leaders can communicate, recognize good work, and develop trust.
The document discusses hazard identification and risk assessment for the Radio Frequency Laboratory. It defines key terms like hazard, hazard control, and risk. The purposes of conducting a hazard identification, risk assessment, and risk control (HIRARC) process are outlined. Types of hazards like health, safety and environmental hazards are described. The steps of HIRARC including classifying work activities, identifying hazards, risk assessment, preparing risk control plans and reviewing are summarized. Methods of qualitative, semi-quantitative and quantitative risk analysis are also highlighted.
This document outlines the steps for conducting an effective accident investigation:
1) Immediately respond to the accident and secure the site.
2) Investigate by determining the 5 Ws and collecting evidence through interviews and photos.
3) Analyze the data to determine the root causes such as equipment issues, environmental factors, human errors, or management failures.
4) Recommend corrective actions and implement solutions permanently through standard procedures and communication. The goal is to prevent future accidents.
This document provides an overview of behavior-based safety. It defines key concepts like activators, behaviors, and consequences using the ABC model of behavior change. Unsafe behaviors, not incidents or injuries, are identified as the root cause of 96% of injuries. The power of consequences on behaviors is emphasized, with positive reinforcement being the most effective at increasing safe behaviors. A behavior-based safety program involves pinpointing critical behaviors, communicating expectations, conducting observations to provide feedback, and using data to reinforce safe behaviors and correct unsafe ones. The goal is to measure and modify behaviors to drive cultural and accident rate improvements over time.
Accident direct cost & indirect costSachin Patil
This document defines accidents and incidents in the workplace. It identifies unsafe acts and conditions that can indirectly or directly contribute to accidents. Some consequences of accidents are immediate injuries or damage, while others emerge over short or long term, negatively impacting victims, supervisors, organizations, and societies. The costs of accidents include both insured expenses like medical treatment and compensation, as well as hidden uninsured costs like lost productivity and profits. Several theories attempt to model relationships between injury severity and non-injury incidents. Most accidents are considered preventable through addressing unsafe acts by workers and unsafe conditions through management controls and supervision.
The document discusses guidelines for investigating incidents in an organization. It covers:
1. The importance of investigating all incidents, including near misses, to identify root causes and prevent recurrences.
2. Organizational preparation for incidents, including communication plans, training employees, and determining investigation procedures.
3. Guidelines for investigations, including involving multiple perspectives, collecting data through interviews and documentation, and focusing on system-level causes rather than individual blame.
Behavior based safety how thinking safe leads to acting safeHNI Risk Services
Behavior based safety programs focus on identifying and controlling the root causes of unsafe behaviors through proactive education, motivation, reinforcement, and improvement efforts. The key aspects of developing an effective behavior based safety system include getting employee support, identifying key safety behaviors, conducting observations to provide feedback, and continuously improving the system by setting new safety goals. Behavior based safety uses a systematic approach centered on decision making and leading indicators rather than injuries and focuses on building a positive safety culture.
Work at height refers to any work where a person could fall and be injured, including work at or below ground level. A work permit is required to ensure hazardous jobs are carried out safely. Safe work at heights involves avoiding work at heights if possible, preventing falls through fall protection devices like safety nets and harnesses, and using the proper access equipment like ladders, scaffolds, and mobile elevated work platforms. Proper erection, use, and inspection of this equipment is necessary to minimize fall risks.
This document outlines the phases and steps of completing a risk analysis. It discusses (1) analyzing risks by identifying assets, threats, vulnerabilities and risks; (2) developing countermeasures through mitigation opportunities and policy planning; and (3) applying the process in practice using a small business example. The goal is to characterize, define, mitigate and eliminate risks to protect assets.
Incident Investigation Safety Training 2015KyleMurry
The document provides guidance on conducting incident investigations. It discusses gathering facts at the incident scene through witness interviews and evidence collection. Key steps in the investigation process include responding immediately, fact-finding through structured interviews and analysis of equipment, personnel, environment and processes involved. The goal is to identify root causes to control and eliminate them, thereby preventing reoccurrence. Corrective actions should be documented and their effectiveness measured. Fraud indicators known as "red flags" should also be considered. Prompt reporting allows for immediate medical care and investigation to implement controls. The hierarchy of control model outlines approaches from elimination and substitution to administrative and personal protective equipment controls.
Mock Drills in Hospitals- How to conduct mock drills?Lallu Joseph
Internal disaster management in hospitals is very critical. Hospitals need to prepared to handle emergencies and conduct regular mock drills to check the protocols, awareness of staff and also the equipment.
All employers must conduct a risk assessment to identify hazards and risks. A sample risk assessment is provided for a school production of Beauty and the Beast to illustrate what should be included. Hazards identified include slips and trips, use of ladders and rigging lights, pyrotechnics, falling off the stage, hitting heads under the stage, using scaffolding, dropping heavy equipment, reaching high shelves, spraying flammable coating, and splinters. For each hazard, those who may be harmed, existing controls, and any additional actions needed are described. The risk assessment should be reviewed if circumstances change.
4 Cofferdams (Temporary Works) Risk Assessment Templates
Planned Cofferdam excavation in areas where live services may be present including:
• Electrical;
• Water;
• Sewerage;
• Gas;
• Telecoms;
PRIOR TO WORKS
Cofferdam Design under Temporary Works
Cofferdam excavation
Cofferdam sheet piling
Lifting operations
Confined space working – cofferdam
Installation of wales, bracing etc.
Maintenance of cofferdam
MiCAH Safety Solutions has developed this training presentation to assist employers in educating their employees in OSHA Standard 1926 Subpart M. This training has been developed through careful and extensive research in the subject matter, and has been used to successfully train hundreds of employees for several companies. It is unique in it's design, using high impact visual imagery to capture the minds of trainees as they learn the required content.
We offer this training free to anyone to use, and ask only that it not be reproduced or redistributed for sale. We hope that you find our training to be a benefit and desire any feedback that you may have.
For more information on our unique training presentations, customized presentations for your company, or our onsite or online training options visit www.micahsafetsyolutions.com or call us at 844-822-1294.
Establishing and fostering a safety culture has, quite rightly, become a more prominent topic to consider for safety directors. No matter the industry or organization, it is now commonly accepted that safety culture can have a huge influence on the success or failure of a safety management system.
Safety culture is not a program, policy or procedure, it is a reflection of how safety is managed in a workplace. However, it is often difficult to pin down, as it is a somewhat ethereal concept, based on soft components that cannot be easily measured – factors such as accountability, leadership and organizational learning.
This difficulty is at the heart of many safety directors’ struggle – how do you pinpoint your organization’s current safety culture? Which activities are having a positive or negative effect?
In this presentation, Shannon Crinklaw defines safety culture and provide suggestions and ideas around how to recognize and foster a strong safety culture within your organization.
Watch this webinar and learn:
How safety culture can be broken down into components
The different ways that it can be (indirectly) measured
Steps that managers should take to improve it
How using Medgate to automate some safety activities assist in building a safety culture
This document discusses risk assessments and risk management. It outlines three types of risk assessments: baseline, issue-based, and continuous. It emphasizes that risk assessments should be comprehensive, provide a broad picture, and may lead to more in-depth assessments. Risk assessments should be reviewed periodically or when workplace changes occur. The document also outlines an 8-step risk management process and stresses the importance of documentation for auditing purposes.
This document discusses safety procedures for working at heights. It defines working at heights as being 1.5 meters or more above a working platform. It notes that in 2007-2008, 67 people died and nearly 4000 were seriously injured from falls in the workplace. It outlines common factors that lead to accidents, including lack of safe work systems, failure to use proper equipment, and failure to inspect scaffolds. It provides guidelines for safely using scaffolds, ladders, and other equipment and ensuring the safety of workers and the public. It emphasizes the importance of following safe work procedures and using fall protection to prevent incidents.
Job analysis is a systematic approach to collecting information about job tasks, responsibilities, and skills required to perform those tasks. It assists with human resources planning, recruiting, selection, training, performance management, and other functions. There are several methods for conducting job analysis, including observation, interviews, questionnaires, diaries, and critical incident technique. An example is provided of a job analyst categorizing a job into data, people, and things. The document concludes with an exercise walking through steps a customer service manager would take to implement a job analysis using the critical incident technique method.
The document discusses job safety analysis (JSA) and provides an agenda for a training session on JSA. It includes national safety statistics on workplace accidents, definitions related to occupational safety, and a five-step process for conducting a JSA: 1) determining job conditions, 2) breaking down the job into steps, 3) identifying hazards, 4) evaluating hazards, and 5) determining protective measures. The goal of a JSA is to establish safe work methods and recognize hazards associated with jobs.
The document provides an overview of a workshop on effective safety leadership. It discusses John Gardner's view that understanding is the first step of leadership. The workshop aims to help participants gain awareness of leadership concepts and techniques that can be applied in the workplace to promote safety. It includes sections on the nature of leadership, leadership styles, developing a supportive safety culture, and how leaders can communicate, recognize good work, and develop trust.
The document discusses hazard identification and risk assessment for the Radio Frequency Laboratory. It defines key terms like hazard, hazard control, and risk. The purposes of conducting a hazard identification, risk assessment, and risk control (HIRARC) process are outlined. Types of hazards like health, safety and environmental hazards are described. The steps of HIRARC including classifying work activities, identifying hazards, risk assessment, preparing risk control plans and reviewing are summarized. Methods of qualitative, semi-quantitative and quantitative risk analysis are also highlighted.
This document outlines the steps for conducting an effective accident investigation:
1) Immediately respond to the accident and secure the site.
2) Investigate by determining the 5 Ws and collecting evidence through interviews and photos.
3) Analyze the data to determine the root causes such as equipment issues, environmental factors, human errors, or management failures.
4) Recommend corrective actions and implement solutions permanently through standard procedures and communication. The goal is to prevent future accidents.
This document provides an overview of behavior-based safety. It defines key concepts like activators, behaviors, and consequences using the ABC model of behavior change. Unsafe behaviors, not incidents or injuries, are identified as the root cause of 96% of injuries. The power of consequences on behaviors is emphasized, with positive reinforcement being the most effective at increasing safe behaviors. A behavior-based safety program involves pinpointing critical behaviors, communicating expectations, conducting observations to provide feedback, and using data to reinforce safe behaviors and correct unsafe ones. The goal is to measure and modify behaviors to drive cultural and accident rate improvements over time.
Accident direct cost & indirect costSachin Patil
This document defines accidents and incidents in the workplace. It identifies unsafe acts and conditions that can indirectly or directly contribute to accidents. Some consequences of accidents are immediate injuries or damage, while others emerge over short or long term, negatively impacting victims, supervisors, organizations, and societies. The costs of accidents include both insured expenses like medical treatment and compensation, as well as hidden uninsured costs like lost productivity and profits. Several theories attempt to model relationships between injury severity and non-injury incidents. Most accidents are considered preventable through addressing unsafe acts by workers and unsafe conditions through management controls and supervision.
The document discusses guidelines for investigating incidents in an organization. It covers:
1. The importance of investigating all incidents, including near misses, to identify root causes and prevent recurrences.
2. Organizational preparation for incidents, including communication plans, training employees, and determining investigation procedures.
3. Guidelines for investigations, including involving multiple perspectives, collecting data through interviews and documentation, and focusing on system-level causes rather than individual blame.
Behavior based safety how thinking safe leads to acting safeHNI Risk Services
Behavior based safety programs focus on identifying and controlling the root causes of unsafe behaviors through proactive education, motivation, reinforcement, and improvement efforts. The key aspects of developing an effective behavior based safety system include getting employee support, identifying key safety behaviors, conducting observations to provide feedback, and continuously improving the system by setting new safety goals. Behavior based safety uses a systematic approach centered on decision making and leading indicators rather than injuries and focuses on building a positive safety culture.
Work at height refers to any work where a person could fall and be injured, including work at or below ground level. A work permit is required to ensure hazardous jobs are carried out safely. Safe work at heights involves avoiding work at heights if possible, preventing falls through fall protection devices like safety nets and harnesses, and using the proper access equipment like ladders, scaffolds, and mobile elevated work platforms. Proper erection, use, and inspection of this equipment is necessary to minimize fall risks.
This document outlines the phases and steps of completing a risk analysis. It discusses (1) analyzing risks by identifying assets, threats, vulnerabilities and risks; (2) developing countermeasures through mitigation opportunities and policy planning; and (3) applying the process in practice using a small business example. The goal is to characterize, define, mitigate and eliminate risks to protect assets.
Incident Investigation Safety Training 2015KyleMurry
The document provides guidance on conducting incident investigations. It discusses gathering facts at the incident scene through witness interviews and evidence collection. Key steps in the investigation process include responding immediately, fact-finding through structured interviews and analysis of equipment, personnel, environment and processes involved. The goal is to identify root causes to control and eliminate them, thereby preventing reoccurrence. Corrective actions should be documented and their effectiveness measured. Fraud indicators known as "red flags" should also be considered. Prompt reporting allows for immediate medical care and investigation to implement controls. The hierarchy of control model outlines approaches from elimination and substitution to administrative and personal protective equipment controls.
Mock Drills in Hospitals- How to conduct mock drills?Lallu Joseph
Internal disaster management in hospitals is very critical. Hospitals need to prepared to handle emergencies and conduct regular mock drills to check the protocols, awareness of staff and also the equipment.
All employers must conduct a risk assessment to identify hazards and risks. A sample risk assessment is provided for a school production of Beauty and the Beast to illustrate what should be included. Hazards identified include slips and trips, use of ladders and rigging lights, pyrotechnics, falling off the stage, hitting heads under the stage, using scaffolding, dropping heavy equipment, reaching high shelves, spraying flammable coating, and splinters. For each hazard, those who may be harmed, existing controls, and any additional actions needed are described. The risk assessment should be reviewed if circumstances change.
4 Cofferdams (Temporary Works) Risk Assessment Templates
Planned Cofferdam excavation in areas where live services may be present including:
• Electrical;
• Water;
• Sewerage;
• Gas;
• Telecoms;
PRIOR TO WORKS
Cofferdam Design under Temporary Works
Cofferdam excavation
Cofferdam sheet piling
Lifting operations
Confined space working – cofferdam
Installation of wales, bracing etc.
Maintenance of cofferdam
MiCAH Safety Solutions has developed this training presentation to assist employers in educating their employees in OSHA Standard 1926 Subpart M. This training has been developed through careful and extensive research in the subject matter, and has been used to successfully train hundreds of employees for several companies. It is unique in it's design, using high impact visual imagery to capture the minds of trainees as they learn the required content.
We offer this training free to anyone to use, and ask only that it not be reproduced or redistributed for sale. We hope that you find our training to be a benefit and desire any feedback that you may have.
For more information on our unique training presentations, customized presentations for your company, or our onsite or online training options visit www.micahsafetsyolutions.com or call us at 844-822-1294.
Establishing and fostering a safety culture has, quite rightly, become a more prominent topic to consider for safety directors. No matter the industry or organization, it is now commonly accepted that safety culture can have a huge influence on the success or failure of a safety management system.
Safety culture is not a program, policy or procedure, it is a reflection of how safety is managed in a workplace. However, it is often difficult to pin down, as it is a somewhat ethereal concept, based on soft components that cannot be easily measured – factors such as accountability, leadership and organizational learning.
This difficulty is at the heart of many safety directors’ struggle – how do you pinpoint your organization’s current safety culture? Which activities are having a positive or negative effect?
In this presentation, Shannon Crinklaw defines safety culture and provide suggestions and ideas around how to recognize and foster a strong safety culture within your organization.
Watch this webinar and learn:
How safety culture can be broken down into components
The different ways that it can be (indirectly) measured
Steps that managers should take to improve it
How using Medgate to automate some safety activities assist in building a safety culture
This document discusses risk assessments and risk management. It outlines three types of risk assessments: baseline, issue-based, and continuous. It emphasizes that risk assessments should be comprehensive, provide a broad picture, and may lead to more in-depth assessments. Risk assessments should be reviewed periodically or when workplace changes occur. The document also outlines an 8-step risk management process and stresses the importance of documentation for auditing purposes.
This document discusses safety procedures for working at heights. It defines working at heights as being 1.5 meters or more above a working platform. It notes that in 2007-2008, 67 people died and nearly 4000 were seriously injured from falls in the workplace. It outlines common factors that lead to accidents, including lack of safe work systems, failure to use proper equipment, and failure to inspect scaffolds. It provides guidelines for safely using scaffolds, ladders, and other equipment and ensuring the safety of workers and the public. It emphasizes the importance of following safe work procedures and using fall protection to prevent incidents.
Job analysis is a systematic approach to collecting information about job tasks, responsibilities, and skills required to perform those tasks. It assists with human resources planning, recruiting, selection, training, performance management, and other functions. There are several methods for conducting job analysis, including observation, interviews, questionnaires, diaries, and critical incident technique. An example is provided of a job analyst categorizing a job into data, people, and things. The document concludes with an exercise walking through steps a customer service manager would take to implement a job analysis using the critical incident technique method.
The document discusses job safety analysis (JSA) and provides an agenda for a training session on JSA. It includes national safety statistics on workplace accidents, definitions related to occupational safety, and a five-step process for conducting a JSA: 1) determining job conditions, 2) breaking down the job into steps, 3) identifying hazards, 4) evaluating hazards, and 5) determining protective measures. The goal of a JSA is to establish safe work methods and recognize hazards associated with jobs.
This document discusses fostering resilience in individuals and families. It begins with an introduction explaining that promoting resilience is cost effective, can expedite recovery from difficult situations, facilitate a return to normalcy, minimize secondary losses, and have multi-beneficial effects. The document then covers definitions of resilience and vulnerability, determinants of vulnerability and resilience, levels of social resilience, and dimensions of resilience. It also discusses supporting resilience through information and advice, resources, management capacity, personal and community support, and involvement. The document provides recommendations for how individuals can become survivors and ensure long-term recovery.
Here are 22 questions to help focus efforts on identifying and controlling hazards when you conduct a job hazard analysis (JHA).
Note that the list is not complete. You will need to think carefully about the tasks and sub-tasks of each job you analyze and the particular hazards they present. Then you can add or delete to develop suitable lists for jobs you analyze.
Bonus: Learn more about JHA with this handy infographic: http://bit.ly/28Kx8Z1
The document provides an overview of Bengali refugees fleeing to the US state of North Carolina due to catastrophic flooding in Bangladesh. It discusses the cultural beliefs, political structure, religious demographics, health issues, education system, criminal activities, and anticipated burdens the refugees will place on North Carolina's social services. The largest sections cover health indices, diseases, and suggested strategies for helping the refugees adapt to their new homes.
This document discusses hazard identification, risk assessment, and determining controls. It provides definitions of hazards and risk. It explains that hazard identification and risk assessment should involve identifying hazards, assessing risks, determining controls, implementing controls, and managing change. The document outlines a methodology for teams to identify hazards in their work areas by observing work conditions and tasks and using a risk matrix to rate risks and identify existing and needed controls. The overall aim is to provide a systematic approach to evaluating workplace hazards and risks.
To increase the effectiveness of the incident analysis in improving care, analysis can’t be addressed in isolation from incident management (the multitude of activities that take place before and after an incident). Three main topics will be covered in this module: the main steps in the incident management continuum; differentiating between incident analysis (focused on system improvement) and accountability reviews (focused on individual performance), and selecting an incident analysis method.
During this module, the key features and main steps to analyze an incident using the comprehensive method will be described, discussed and applied. In addition, the tools that facilitate a comprehensive analysis will be introduced: the timeline, human factors, diagramming contributing factors and their interconnection (using the constellation diagram), guiding questions and the statements of findings.
Working the Science and Regulations Harder to Win Your Drug and Device CasesSara Dunlap
This webinar will teach critical scientific principles related to the regulatory framework as they pertain to drug and medical device litigation for seasoned in house and outside counsel alike. Examples of topics that will be covered include safety signaling and pharmacovigilance, epidemiological and randomized controlled trial study design, risk management principles, causality assessment, and the strategic role of regulatory guidelines and compliance.
The background, key features and main steps of the concise analysis method are described, discussed and applied in this module together with the main tools used during a concise analysis (timeline, guiding questions, constellation diagram, and statements of findings).
Patient safety Incident (PSI) is an unplanned or unintended event or circumstance that could have resulted or did result in harm to a patient while in the care of a health facility. In this presentation, I explored the concepts of patient safety and patient safety incidents. I also explored the concept of Reporting systems, properly now known as reporting and learning systems - because learning is paramount in the reporting system. I focused on the minimal information model, which is more routinely used compared to the intermediate and full information models.
This document discusses epidemiology and how it was used to identify smoking as a cause of lung cancer. It shows that lung cancer rates increased dramatically between 1937-1950 in the US. A case-control study found that smokers were over 20 times more likely to develop lung cancer than non-smokers. A later British study found that lung cancer risk increased with the number of cigarettes smoked per day. Through observational epidemiological studies, researchers were able to establish smoking as a major risk factor and cause of lung cancer.
This document discusses tools and methods for identifying and controlling patient safety risks. It describes various systems for risk identification, both informal like claims data and formal like incident reporting. Incident reporting aims to identify risks early through staff reporting any incidents or occurrences. The document outlines the content and categories that should be included in incident reports. It also discusses barriers to staff participation in reporting and ways to improve reporting. Sentinel events represent severe risks and require a root cause analysis to identify underlying systemic issues and prevent recurrence.
The document describes creating a just culture of safety in healthcare. It discusses influences on advancing safety culture including professional accountability and a just culture approach. A just culture emphasizes quality and safety over blame, promotes error reporting to uncover root causes, and uses coaching rather than punishment for unintentional errors. Examples of errors are provided to distinguish intentional reckless behavior from mistakes. The document also summarizes Massachusetts General Hospital's approach to developing a just culture including robust safety reporting, data analysis, and leadership involvement.
The document discusses public health surveillance, defining it as the ongoing systematic collection, analysis, and interpretation of health data that is disseminated to those responsible for prevention and control in order to take timely action. It describes the objectives, types (passive, active, sentinel), activities, attributes, and important diseases under surveillance in Ethiopia's Integrated Disease Surveillance and Response system. The goal of surveillance is to serve as an early warning system and guide public health practice.
Patient Safety
Presenter : Dr. Dipendra Bhusal
Moderator: Dr. Sunil Jwarchan
Department of General Surgery
Pokhara Academy of Health Sciences
Introduction
• Increased life expectancy >25years in
over last semicentennial.
The Nature Journal
Law of supply and demand applied to health
services.
• 2 big challenges in proving
safe and effective service,
• greater demand and larger options ,
• increasing complexity in healthcare
• "First, do no harm" is a fundamental healthcare principle prioritizing
patient safety.
• Global evidence indicates a significant burden of avoidable patient
harm across healthcare systems.
• Avoidable patient harm has major implications, including human,
moral, and ethical consequences.
• The prevalence of harm challenges established healthcare principles
and ethics.
• Financial implications accompany the human toll, affecting healthcare
systems globally.
• Defined as “the absence of preventable harm to a patient and
reduction of risk of unnecessary harm associated with health care to
an acceptable minimum”
• to prevent harm to patients,
caused by the process of
health care itself.
Origin of patient safety concept
• HIPPOCRATIC OATH
I will prescribe regimens for the good of my patients according to my
ability and my judgment and ‘never do harm’ to anyone
Improving patient safety means reducing patient harm
CURRENT ENVIRONMENT
• Errors and system failures repeated
• Action on known risk is very slow
• Detection systems in their infancy
• Many events not reported
• Understanding of causes limited
• Blame culture alive and well
• Defensiveness and secrecy
Prevalence of adverse health care event
• WHO estimates that, even in advanced hospital settings, one in ten
patients receiving healthcare will suffer preventable harm
• The report “To Err is Human: building a safer health system” by IOM
of the national academy of health system drew widespread attention
to the alarming statistics that there were between 44000 and 98000
preventable deaths , 7000 related to medication error only.
• If medical error was a disease then it would be 3rd leading cause of
death in USA after heart issues and cancer
Why ERROR?
• Usually not willful negligence, but systemic flaws,
-inadequate communication and wide spread process variation and
patient ignorance.
Patient safety incidents
• An Adverse event: An incident which results in harm to the patient.
• A near miss: An incident that could have resulted in unwanted
consequences but did not either by chance or through a timely
intervention preventing the event from reaching the patient.
• A no harm event: An incident that occurs and reaches the patient but
results in no injury to the patient. Harm is avoided by chance or due
to mitigating circumstances
Common causes of adverse health events
• Preventable Events
• Of these, inadequate communication ranks highest in frequency
Risk-based approach to infectious disease safetyTGA Australia
The document discusses the TGA's risk-based approach to infectious disease safety for therapeutic goods like medicines, medical devices, and biologicals. It explains that the TGA conducts risk assessments to determine which infectious agents pose risks and require risk management measures. The risk assessment process involves identifying hazards, analyzing likelihood and consequences of harm, and evaluating overall risk levels. The TGA is establishing a systematic risk assessment approach using standardized criteria to allow for consistent evaluation and management of risks from infectious diseases in cellular therapies and tissues.
Research design involves decisions about how to collect and analyze data to answer research questions or solve problems. There are two main types of research design: observational studies and experimental studies. Observational studies observe naturally occurring events without intervention, while experimental studies involve deliberate human intervention to change the course of events. Common research designs include descriptive studies, analytical studies, case-control studies, cohort studies, cross-sectional studies, and randomized controlled trials. Research design aims to ensure valid, unbiased conclusions through careful planning of study type, variables, data collection, and statistical analysis.
STH 2017_Day 3_Track 1_Session 1_Caralis_Preventing Medical Errors Compatibil...Benghie Hyacinthe
The document discusses medical errors and strategies to reduce them. It defines medical errors and notes that they are common, causing thousands of deaths annually in the US. Root cause analysis seeks to identify underlying factors in the healthcare system that contribute to errors in order to implement fixes. Strategies discussed include improving communication, using checklists, increasing staff supervision, and optimizing workload and resources to reduce risk. The goal is to learn from errors by examining the system failures that led to them, rather than blaming individuals.
Objectives:
By the end of this call, you will be able to:
•Describe the processes of Root-Cause Analysis (RCA) and Multi-Incident Analysis (MIA) and their role in quality improvement
•Compare and contrast the different approaches to collecting hospital-acquired VTE data
•Identify an approach suitable for improving patient safety at your institution
This document outlines the educational objectives and content for a lecture on epidemiology. The objectives are to define key epidemiology terms, discuss the functions and modes of epidemiologic investigation, and identify sources of data and potential sources of error. The content includes definitions of epidemiology and related terms, the main functions of epidemiology, descriptive and analytic modes of investigation, how surveillance system data is applied through outbreak investigation, and sources of epidemiological data and potential sources of error.
Objectives:
1.Introduce the Measuring and Monitoring of Safety Framework to a Canadian healthcare audience
2.Describe how the framework would work in Canada
Introducing Comprehensive, Concurrent Patient Safety Surveillance for Hospita...Health Catalyst
Health Catalyst is excited to announce the Patient Safety Monitor™ Suite: Surveillance Module, the industry’s first comprehensive patient safety application to use predictive and text analytics combined with concurrent clinician review of data to help monitor, detect, predict and prevent threats to patients before harm can occur.
The Patient Safety Monitor Suite leverages AI and machine learning to quickly identify patterns of harm, learn from those patterns, and suggest strategies to eliminate patient safety risks and hazards. This potent combination of AI, machine learning, text analytics and near real-time data from multiple IT systems enables the Patient Safety Monitor Suite to predict harm events and guide clinical interventions while the patient is still in the hospital.
In this webinar you will learn how the Surveillance Module can provide:
* Greater clarity to the types, numbers, and causes of adverse events, enabling leaders to quickly prioritize improvement efforts.
* Improved patient outcomes such as reduced morbidity, mortality, and length-of-stay, and increased quality-of-life and satisfaction.
* Bottom-line cost savings and improved brand recognition related to unnecessary or preventable high-cost care and reduced/eliminated penalties.
* The ability for clinicians and infection preventionists to focus on patient care instead of burdensome manual data extraction, aggregation, and reporting.
A qualitative and quantitative hazard analysis to provide the public with a reasonable estimate of probability of harm.
Risk Assessment is a science and involves a variety of disciplines to reach an estimate. In an event out of their control, like a release or spill,
the public wants to know how something happened, why it happened, what can happen to them, where they can go for medical assistance if needed, how to get more information, what’s going to be done about it, when will it be done, and how it will be proven that it is safe (and what will be done to prevent this from happening again).
Any data, such as the dose required to cause an infection can be used in creating these estimates. Also, being able to calculate the worst case estimate of the amount released, the dilution factor (environment), the distance to an exposed population, duration of exposure, and individual susceptibilities are a few of the factors involved in determining the risk for the public.
The ability to measure the hazardous agent in air, on surfaces, or within bulk water and soil samples after an incident and again after mitigation goes a long way in estimating the potential risk and ensuring the public.
This document discusses utilizing patient care data from clinical settings for clinical research purposes. It describes the types of data available, common barriers faced, and the need to obtain proper permissions. A variety of research study designs are possible using this data, including descriptive studies, interventional studies, qualitative research, and quality improvement projects. Case studies, case series, surveys and collaboration are recommended approaches. Addressing barriers like permissions and developing research skills can help facilitate use of this valuable data source.
Similar to Module 6 - Multi-Incident Analysis Method (20)
As patients and families impacted by harm, we imagine progressive approaches in responding to patient safety incidents – focused on restoring health and repairing trust.
We can change how we respond to healthcare harm by shifting the focus away from what happened, towards who has been affected and in what way. This is your opportunity to hear about innovative approaches in Canada, New Zealand, and the United States that appreciate these human impacts.
This interactive webinar is hosted by Patients for Patient Safety Canada, the patient-led program of the Canadian Patient Safety Institute and the Canadian arm of the World Health Organization Patients for Patient Safety Global Network.
This interactive webinar is part of the world tour series designed by the World Health Organization's Patients for Patient Safety (PFPS) Global Network and hosted by Patients for Patient Safety Canada, the patient-led program of the Canadian Patient Safety Institute, a WHO Collaborating Centre on Patient Safety and Patient Engagement.
The goal of this virtual discussion is to explore practical solutions for keeping seniors safe. The ideas are drawn from real life experiences noting how COVID-19 impacted seniors, their loved ones as well as healthcare workers and leaders.
The focus of the discussion is on identifying safety risks together with practical solutions for seniors who live at home, in residences and long-term care facilities.
After hearing the perspectives of patients, providers and leaders from Indigenous communities on how they perceive safety and what solutions are/ can be implemented, we will leave the session with at least one practical idea for engaging all patients, families and/or the public in improving patient safety.
Healthcare providers and leaders will address three types of silences in healthcare: organizational silence, patient-related silence, and provider to provider silence.
Read More: www.conquersilence.ca
This document discusses teamwork in healthcare and its importance for patient safety. It describes how teamwork skills are often taught through simulations but clinical experience is limited for undergraduates. The intervention described uses a film about a patient falling through the cracks followed by workshops using scenarios to practice and debrief teamwork skills. Key concepts emphasized include shared understanding of goals and plans, involving patients as part of the team, and skills like adaptation, trust, and psychological safety. The overall goal is to apply teamwork knowledge to improve patient outcomes and safety.
Enhanced Recovery After Surgery (ERAS®) is the Enhanced Recovery After Surgery (ERAS®) is the implementation of patient-focused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidence-based, interdisciplinary perioperative guidelines.
Learn more about Enhanced Recovery Canada:
http://ow.ly/hR3j30jsnjR
Dr. Dee Mangin, Professor of Family Medicine and the Associate Chair and Director, Research, at McMaster University, will join practicing pharmacist, and Vice President, Pharmacy Affairs, Sandra Hanna of the Neighbourhood Pharmacy Association of Canada to discuss medication risks, deprescribing and the dangers of polypharmacy in this one hour webinar. Learn more at www.asklistentalk.ca
Joshua Myers, Terry Brock - Fraser Health (BC) - We Want to Hear from You: Fraser Health Real-Time Experience Survey
Leading organizations in Canada invite, listen and act on feedback from patients in their care to improve the safety and quality of care. Explore the three award-winning practices linked below then join us in a conversation to learn more about each approach and reflect on how you may apply it in your organization. This webinar promises practical ideas to help you engage patients in making care safer.
Leading organizations in Canada invite, listen and act on feedback from patients in their care to improve the safety and quality of care. Explore the three award-winning practices linked below then join us in a conversation to learn more about each approach and reflect on how you may apply it in your organization. This webinar promises practical ideas to help you engage patients in making care safer.
Cathy Masuda, Leslie Louie - BC Children's Hospital, an Agency of the Provincial Health Services Authority -Patient's View: Engaging Patients and Families in Patient Safety Incident Reporting
Leading organizations in Canada invite, listen and act on feedback from patients in their care to improve the safety and quality of care. Explore the three award-winning practices linked below then join us in a conversation to learn more about each approach and reflect on how you may apply it in your organization. This webinar promises practical ideas to help you engage patients in making care safer.
Alberta Health Services: Family Volunteers or Advisors Gathering Real-time Patient Experiences
Leading organizations in Canada invite, listen and act on feedback from patients in their care to improve the safety and quality of care. Explore the three award-winning practices linked below then join us in a conversation to learn more about each approach and reflect on how you may apply it in your organization. This webinar promises practical ideas to help you engage patients in making care safer.
This final webinar will emphasise the importance of understanding the problem before brainstorming solutions to better ensure a match between barriers and the solutions.
MORE INFO: http://bit.ly/2KctiLH
This webinar provides an overview of key frameworks for identifying barriers and enablers to implementation, with a focus on the Theoretical Domains Framework (TDF). The TDF synthesizes 128 constructs from 33 theories of behavior change into 12 domains to understand factors influencing healthcare professionals' behaviors. The webinar uses a case study of improving physician hand hygiene to demonstrate how the TDF can be applied to identify potential barriers within domains like Knowledge, Skills, Social Influences, and Environmental Context & Resources.
The fifth webinar continues the momentum of the series as it focuses on providing concrete approaches for identifying barriers and enablers, emphasising behaviour change approaches.
READ MORE: http://bit.ly/2LOwbj0
Please join CPSI as we conclude our Human Factors webinar series with our final presentation Collaborative "Spaces" and Health Information Technology Design
Professor Benedetta Allegranzi,World Health Organisation
Dr. Benedetta Allegranzi is a specialist in infectious diseases, tropical medicine, infection prevention and control and hospital epidemiology. She currently works at the World Health Organization HQ (Service Delivery and Safety department), leading the "Clean Care is Safer Care" programme. Since 2013, Dr Allegranzi has gathered the title of professor of infectious diseases in the official Italian professorship list and is adjunct professor attached to the Institute of Global Health at the Faculty of Medicine, University of Geneva, Switzerland. She closely collaborates with the team at the IPC and WHO Collaborating Center on Patient Safety, University of Geneva Hospitals (Geneva, Switzerland), as well as with the Armstrong Institute for Patient Safety and Quality, John Hopkins University, (Baltimore, USA) for clinical research projects. She is currently involved in the leadership on the WHO Ebola Response in the field of IPC and supervises IPC activities in Sierra Leone and Guinea. She has experience in clinical management of infectious diseases and tropical medicine, and clinical research in healthcare settings in both developing and developed countries. She has thorough skills and experience in training and education.
She is also the author or coauthor of more than 150 scientific publications, including articles published in high-profile medical journal such as the Lancet, Lancet Infectious Diseases, New England Journal of Medicine and the WHO Bulletin, and six book chapters.
Lori Moore joined GOJO Industries in 2013 as a Clinical Application Specialist. In this position, she provided leadership and support to healthcare organizations as they implemented electronic compliance monitoring (ECM) to more accurately measure hand hygiene performance. She has been a trusted partner to hospital key stakeholders in the development, design and implementation of hand hygiene improvement efforts. Areas of expertise include root cause analysis with targeted solutions, just-in-time coaching and ECM software data analytics. In January 2017, she transitioned to the position of Clinical Educator for Healthcare.
She began her professional career in healthcare in 2010 as a registered nurse in the medical intensive care unit at the Cleveland Clinic Foundation (where she continues to work on the weekends). Her passion for patient safety and quality of care sparked her interest in infection prevention, and she worked as an infection preventionist prior to joining GOJO.
Lori has a well-rounded academic background which includes a Bachelor’s of Arts in Management from Malone College, a Bachelor’s of Science in Nursing from the University of Akron, and a Master’s degree in Public Health from the University of Akron. She is a member of the Association for Professionals in Infection Control and Epidemiology, American Society of Professionals in Patient Safety, and the American Medical Writers Association. She has also earned the credential of Certified Health Education Specialist (CHES) and Certified Professional in Patient Safety (CPPS).
The third interactive webinar in the series builds on the second session by focusing on the question: once we have evidence to justify implementing a new patient safety initiative, what next?
STUDIES IN SUPPORT OF SPECIAL POPULATIONS: GERIATRICS E7shruti jagirdar
Unit 4: MRA 103T Regulatory affairs
This guideline is directed principally toward new Molecular Entities that are
likely to have significant use in the elderly, either because the disease intended
to be treated is characteristically a disease of aging ( e.g., Alzheimer's disease) or
because the population to be treated is known to include substantial numbers of
geriatric patients (e.g., hypertension).
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
Are you looking for a long-lasting solution to your missing tooth?
Dental implants are the most common type of method for replacing the missing tooth. Unlike dentures or bridges, implants are surgically placed in the jawbone. In layman’s terms, a dental implant is similar to the natural root of the tooth. It offers a stable foundation for the artificial tooth giving it the look, feel, and function similar to the natural tooth.
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga
GASTROINTESTINAL INFECTIONS AND GASTRITIS
Osvaldo Bernardo Muchanga
Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
Among the factors that lead to the occurrence of gastrointestinal infections are the hygienic and sanitary deficiencies that characterize our markets and other places where raw or cooked food is sold, poor environmental sanitation in communities, deficiencies in water treatment (or in the process of its plumbing), risky hygienic-sanitary habits (not washing hands after major and/or minor needs), among others.
These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
The treatment consists of replacing lost liquids and electrolytes (drinking drinking water and other recommended liquids, including consumption of juicy fruits such as papayas, apples, pears, among others that contain water in their composition).
To prevent this, it is necessary to promote health education, improve the hygienic-sanitary conditions of markets and communities in general as a way of promoting, preserving and prolonging PUBLIC HEALTH.
Gastritis and Gastric Health
Gastric Health is one of the most relevant concerns in human health, with gastrointestinal infections being among the main illnesses that affect humans.
Among gastric problems, we have GASTRITIS AND GASTRIC ULCERS as the main public health problems. Gastritis and gastric ulcers normally result from inflammation and corrosion of the walls of the stomach (gastric mucosa) and are generally associated (caused) by the bacterium Helicobacter pylor, which, according to the literature, this bacterium settles on these walls (of the stomach) and starts to release urease that ends up altering the normal pH of the stomach (acid), which leads to inflammation and corrosion of the mucous membranes and consequent gastritis or ulcers, respectively.
In addition to bacterial infections, gastritis and gastric ulcers are associated with several factors, with emphasis on prolonged fasting, chemical substances including drugs, alcohol, foods with strong seasonings including chilli, which ends up causing inflammation of the stomach walls and/or corrosion. of the same, resulting in the appearance of wounds and consequent gastritis or ulcers, respectively.
Among patients with gastritis and/or ulcers, one of the dilemmas is associated with the foods to consume in order to minimize the sensation of pain and discomfort.
Nano-gold for Cancer Therapy chemistry investigatory projectSIVAVINAYAKPK
chemistry investigatory project
The development of nanogold-based cancer therapy could revolutionize oncology by providing a more targeted, less invasive treatment option. This project contributes to the growing body of research aimed at harnessing nanotechnology for medical applications, paving the way for future clinical trials and potential commercial applications.
Cancer remains one of the leading causes of death worldwide, prompting the need for innovative treatment methods. Nanotechnology offers promising new approaches, including the use of gold nanoparticles (nanogold) for targeted cancer therapy. Nanogold particles possess unique physical and chemical properties that make them suitable for drug delivery, imaging, and photothermal therapy.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
3. Learning Program
What was learned?
What can be done?
How and why?
What happened?
Multi-incident
Concise
Comprehensive
4. Learning Objectives
The rationale behind and understanding of the methodology
for multi-incident analysis.
Outline the steps required to undertake a multi-incident
analysis
Give examples of when a multi-incident analysis is
recommended
Agenda
Knowledge + Q&A Practice + Q&A Learn together
5. Introducing: WebEx
Be prepared to use:
- Raise Hand & Checkmark
- Chat & Q&A
- Pointer & Text
5
22-Feb-13 5
6. About You
0 Knowledge of [any] MULTI-INCIDENT analysis 10
9. Types of Multi-Patient Incident
Analyses
Type 1 – Analysis of Many Previous Single-Patient
Incidents/Reviews
A. Homogeneous incidents/reviews over a period of
time
B. Heterogeneous incidents/reviews over a period of
time
Varying degrees of harm (including near miss)
AKA: cluster, aggregate, meta-analysis
Type 2 – Analysis of a Group of Patients Who Have /
May Have Been Impacted by an Incident
Varying degrees of harm (unknown to severe)
AKA: look-backs
10. Why?
Type 1 – Analysis of Many Previous Single-Patient
Incidents/Reviews
To identify themes, relative frequencies of incidents
and/or contributing factors; assess trends over time;
assess implementation of recommendations; obtain
“forest” perspective
Type 2 – Analysis of a Group of Patients Who Have / May
Have Been Impacted by an Incident
To identify if harm occurred (threshold determination
key); and if so, who was impacted
Then, as per single (comprehensive) analysis, to identify
how and why it occurred, what can be done to reduce risk
Usually feeds into multi-patient notification
15. Type 2: Usual Suspects
1. Diagnostics (especially
pathology)
2. Infection Control
3. Privacy Breach
16. Type 2: Examples
• Toronto (1994) • Toronto (2011)
o Blood/look-back o Risk of nosocomial
process infection
• Toronto (2003) • BC (2011)
o Equipment Cleaning
o Radiology
• Newfoundland (2005)
o Pathology
• Alberta (2012)
o Pathology, Radiology
• Southern Ontario (2010)
o Pathology • Everywhere (2010, 2011,
• Toronto (2011) 2012, 2013)
o Actual Nosocomial o Loss of personal health
infection information
18. Prepare (Type 1)
1. Determine the theme and inclusion criteria
2. Gather data
3. Convene an interdisciplinary team
4. Review literature and obtain expert opinions to
lend perspective to the analysis
5. Develop the analysis plan and prepare the
materials
19. Prepare (Type 2)
1. Convene an interdisciplinary team
2. Obtain expert opinions
• clinical, epidemiological, risk management
3. Establish look back plan and gather data
• carefully consider expected false negative and
positive rates, particularly when using newer, more
sensitive test methods
4. Assess results
5. Plan disclosure (if required)
• clinical, epidemiological, ethical, legal/insurer(s),
professionals
21. What (Type 1)
• Review incident reports and/or analyses and
supporting information
• Review additional information: policies, procedures,
literature, environmental scan, previously reported
incidents, previous analyses, consultations with
colleagues or experts, etc.
• Compare and contrast the incident reports and/or
analyses that comprise the themed analysis (can use
process mapping)
• Complete quantitative analysis (descriptive
statistics)
22. How and Why (Type 1)
• Complete a qualitative analysis:
• Compare and contrast contributing factors
and/or recommended actions to look for
common trends or themes
• Summarize findings
• Include any trends, patterns of contributing
factors, and any other findings
23. What Can Be Done (Type 1)
• Develop recommended
actions
• Suggest an order of priority
• Forward to applicable
decision maker(s) for final
decisions and actions
• Manage recommended
actions
24. Then...
Follow-through
• Implement
• Monitor
• Assess
Close the Loop
• Share what was learned
o Internally
o Externally (Publish?)
48. Options
Q&A with the 2 presenters
• Main room
Learn from each other
• Whiteboard 1: Meta-analysis
o Analysis of many previous single-patient incidents
• Whiteboard 2: Multi-patient
o Analysis of a group of patients impacted by an incident
49. Recap and Next Steps
End of session evaluation - tomorrow
Follow up survey – 6 months
• Follow-through and share
what was learned
March 28, 2013
• Recommendations
management
March 7, 2013