the constellation diagram a deeper dive
Post on 21-Oct-2014
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DESCRIPTION
The diagramming step of the incident analysis process is focused on recognizing all system issues that may have contributed to the incident rather than just the factors that are apparent and closer to the point of incident occurrence. The Constellation Diagram can assist teams to better understand systemic factors and the inter-relationships between them, better visualize these relationships, and help avoid the trap of hindsight bias. Diagramming is one of the elements that can increase the credibility, reliability and effectiveness of analysis in making care safer.TRANSCRIPT
The Constellation Diagram A deeper dive
Welcome
Ioana Popescu Nadine Glenn Arlene Pelley Erin Pollock
Program Overview
• Welcome and Introduction
• Constellation Diagram
o Theory
o Case
o Tools – you already have it!
• Q&A
• Participant Presentation and Discussion
• Wrap up and Poll
Questions/ comments: CHAT
Learning Objectives
What
Why
How
5
Introducing: WebEx
4-Sep-13 5
Be prepared to use: - Chat - Raise Hand - Large arrow - Emoticons
About YOU
About You
How familiar are you with the Constellation Diagram?
Never heard of it ………..……X……………………………X……....….. Can’t analyze without it
Theory Overview
Ioana Popescu
The Big Picture
What
Why
- Systematic, structured, and at the same time organic process
- Focus with more precision on where the greatest risks are
- Identify & visualize relationships, interconnections, influences among contributing factors
- Analysis is more thorough and credible (p. 24)
- Avoid cognitive traps (p. 25)
Who
Depends on the type of analysis
• Comprehensive—The entire analysis team participates
• Concise—Usually the analysis lead
• Multi-Incident—Team.
Supporting tool: Guiding Questions (Appendix G, Canadian Incident Analysis Framework)
How
5 Steps • Step 1: Describe the incident
• Step 2: Identify potential contributing factors
• Step 3: Define inter-relationships between and among potential contributing factors.
• Step 4: Identify the findings
• Step 5: Confirm the findings with the team
Practice
Carolyn Hoffman
Case: Wrong Site Surgery
Review
• Scenario
• Timeline
• Additional information
Case: Wrong Site Surgery
Prep Work
- What do we need to know before the team meeting?
Team meeting
- The largest Comprehensive Analysis Team Meeting ever!
- Benefits/risks of a team meeting
- Tips for success
Case: Wrong Site Surgery
Diagramming
Case: Wrong Site Surgery
Next Steps – engage & strive for highest level of effectiveness for recommendations
Case: Wrong Site Surgery
Resources
http://www.globalpatientsafetyalerts.com/English/Pages/default.aspx
Case: Wrong Site Surgery
Resources
Case: Wrong Site Surgery
Resources
Case: Wrong Site Surgery
Resources
http://www.saferhealthcarenow.ca/EN/Interventions/SafeSurgery/Pages/SurgicalSafetyChecklist.aspx
Q&A
Guest Speaker
Melanie Henderson
Discussion