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Causal AnalysisTodd Pawlicki
Just Culture
Reporting Culture
Causal Analysis
Equipment
Organization
People
5 sec to find the lung tumor on the CT scanGorillas in our midst: sustained inattentional blindness for dynamic events – Simons et. al. – Perception, 1999, 28(9), p1059
Youtube: Dan Ariely asks, Are we in control of our decisions?
We are controlled by our biases
We are controlled by our biases
Youtube: Dan Ariely asks, Are we in control of our decisions?
Youtube: Dan Ariely asks, Are we in control of our decisions?
The Incident
Patient JP was treated to a larger volume than necessary because the MR scan wasn’t fused before the plan was completed.
Primary Radiation Oncologist
Covering Radiation Oncologist
Dosimetrist
IT
Operations Manager
What HappenedText goes here
Why It HappenedText goes here
RecommendationsText goes here
ImplementationText goes here
For Each Group
Moderator
Note Taker
Story Teller
