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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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Incident Analysis Learning Program - Module Two The Essentials: Principles, Concepts and Leading Practices Thursday, November 29, 2012
Welcome
Sandi Kossey Ioana Popescu Carrie-Lynn Haines Tina Cullimore
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.
Agenda
1. Case study
2. Theory
3. Small group discussion
5 6-Dec-12 5
Be prepared to use:
• Text tool for annotations
• Q&A and chat for questions
• Emoticons for interactions
The Virtual Meeting Room
Where are you from?
Click on “T” click on
the map type X
International: (type here)
About You
0 Familiarity with the Canadian Incident Analysis Framework 10
0 Familiarity with incident analysis / management 10
Part 1: Case Study
Melissa Griffin, University Health Network
Denise Melanson
http://www.cbc.ca/news/health/story/2007/05/08/chemotherapy-report.html
Components Used to Deliver Medication
http://www.ismp-canada.org/download/reports/FluorouracilIncidentMay2007.pdf
Medication Order
http://www.ismp-canada.org/download/reports/FluorouracilIncidentMay2007.pdf
Drug Label
http://www.ismp-canada.org/download/reports/FluorouracilIncidentMay2007.pdf
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
Confirmation Bias
http://www.ismp-canada.org/download/reports/FluorouracilIncidentMay2007.pdf
Video
Culture Shift
Q&A
Part 2: Theory Burst - Principles
Jennifer White, Saskatchewan Ministry of Health
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
Consistency and Fairness
Team Approach
Confidentiality
Theory Burst - Concepts
Swiss Cheese Model
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).
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.
Complexity Science
Sphere of Influence
Incident:
Outcome:
Task
Equipment
Work Environment
PatientCare Team
Organization
System
Other
Factor
Factor
Factor
Factor
Factor
FactorFactor
Factor
Factor
Factor
FactorFactor Factor
Factor
Factor
FactorFactor
Factor
Factor
Actionable Factor
Actionable Factor
Actionable Factor
Actionable FactorActionable
FactorActionable
Factor
Actionable Factor
Actionable Factor
Actionable Factor
Incidental Finding
Incidental Finding
Incidental Finding
Incidental Finding
Factor Factor
Systems Levels
Context
Leading Practices
Features Timely
Interdisciplinary Objective, impartial
Thorough Detail
Analysis Recommended actions
Documentation Follow-through
Credible Those associated with the
incident Leadership Information
Evaluation plan
LEARN
Cognitive Traps
Types of cognitive bias affecting outcome of an analysis: • Oversimplification • Overestimation • Overrating • Misjudging • Premature completion • Overconfidence
Cognitive Traps
How bias can contribute to a patient safety incident: • Confirmation Bias • Inattention Bias
Q&A
Part 3: Applied Learning
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”
Breakout Session
Current Status
Just culture Consistency, fairness
Team approach Confidentiality
Systems thinking (levels, context, influence)
Human factors
Discuss: barriers - solutions
Write a goal
“Tomorrow I/we will….”
Report Back
Key Lessons/ Points
Wrap-up
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
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: [email protected]
Thank You
Mulţumesc
Just in case slides
Principles
Concepts
Leading Practices
Features Timely
Interdisciplinary Objective, impartial
Thorough Detail
Analysis Recommended actions
Documentation Follow-through
Credible Those associated with the
incident Leadership Information
Evaluation plan
LEARN
