Identify Defects Module Alternate Text
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Slide 1 Cover Slide |
(CUSP Toolkit logo) | The "Identify Defects Through Sensemaking" module of the Comprehensive Unit-Based Safety Program (CUSP) Toolkit. The CUSP Toolkit is a modular approach to patient safety, and modules presented in this toolkit are interconnected and are aimed at improving patient safety. | |||||||||||||||
Slide 2 CUSP and Sensemaking Tools |
CUSP Tools
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Slide 3 Learning Objectives |
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Slide 4 The Relationship Between CUSP and Sensemaking1,2,3 |
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CUSP and Sensemaking use different terms to identify defects or errors. CUSP uses the term "defect" while Sensemaking uses the term "failure" and further classifies failures as (1) human/active failure or (2): latent/system conditions. CUSP uses the Staff Safety Assessment and Status of Safety Issues Worksheet to identify defects. Sensemaking uses the Discovery Form, Root Cause Analysis, Failure Mode and Effects Analysis, and Probabilistic Risk Assessment tools to identity failures. CUSP uses the Learn From Defects Form to examine defects while Sensemaking uses the Causal Tree Worksheet to examine failures. CUSP uses the Learn From Defects Form to code defects, while Sensemaking uses the Eindhoven Model to code failures. |
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Slide 5 Identify Defects and Use Sensemaking |
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Slide 6 Identify Defects Overview |
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Slide 7 Sensemaking Overview4 |
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Slide 8 Examples of Defects or Errors That Affect Patient Safety |
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The table presents a series of defects and their interventions:
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Slide 9 Reason's Swiss Cheese Model5 |
Four slices of Swiss cheese with an arrow passing through the aligned holes. The blunt end of the arrow is labeled "Hazards," and the sharp end is labeled "Losses." | ||||||||||||||||
Slide 10 CUSP Tools to Identify Defects |
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Slide 11 Staff Safety Assessment |
Step 1: What are clinical or operational problems that have or could have jeopardized patient safety? Step 2: How might the next patient be harmed in our unit? Step 3: What can be done to minimize harm or prevent safety hazards? |
Image of the Staff Safety Assessment Form with three arrows pointing at it. The top arrow contains the text: What are clinical or operational problems that have or could have jeopardized patient safety? The middle arrow contains the text: How might the next patient be harmed in our unit? The bottom arrow contains the text: What can be done to minimize harm or prevent safety hazards?. | |||||||||||||||
Slide 12 Exercise |
Please complete the following:
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Slide 13 Use the Safety Issues Worksheet for Senior Executive Partnership |
Step 1. Engage the senior executive in addressing the safety issues identified on the form. Step 2. Use the form during safety rounds to identify safety issues, identify potential solutions, and identify resources. Step 3. Keep the project leader apprised of the information on this form. |
Image of Safety Issues Worksheet for Senior Executive Partnership with three arrows pointing at it. The top arrow contains the text: Step 1. Engage the senior executive in addressing the safety issues identified on the form. The middle arrow contains the text: Step 2. Use the form during safety rounds to identify safety issues, identify potential solutions, and identify resources. The bottom arrow contains the text: Keep the project leader apprised of the information on this form. | |||||||||||||||
Slide 14 Sensemaking Tool to Identify Defects: Root Cause Analysis |
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Slide 15 Root Cause Analysis: Causal Tree Worksheet5 |
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The causal tree is made up of five rows. At the top of the tree and at the top row is where the discovery event would go. The discovery event addresses what happened. The next two rows are labeled antecedent events and would contain the answers to a series of "whys" to help understand the root causes of the event, which would go in the next row on the tree. The last row would contain the root cause classification codes, which will be discussed later in this presentation. The left side of the tree is labeled the failure side, and a small part of the right side is labeled the recovery side. The recovery side is only completed if something prevented the event from reaching the patient. | |||||||||||||||
Slide 16 Root Cause Analysis Example5 |
Discovery Event
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A Causal Tree shows that the discovery event is a Group O patient almost given Group A blood. Recovery occurred when a nurse interrupting the transfusion because the nurse noticed that the unit was A positive As part of the root cause analysis, the following antecedent events are identified:
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Slide 17 Learning From Defects and Sensemaking |
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Slide 18 Learning From Defects Overview |
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Slide 19 Exercise |
Think of an unexpected situation that you recently encountered:
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Slide 20 CUSP Tools to Learn From Defects |
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Slide 21 Learning From Defects: Four Questions |
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Each question is in a box, and the boxes are stacked. An arrow leads down from the bottom of each of the first three boxes to the top of the next box, showing how one question leads to the next. | |||||||||||||||
Slide 22 What Happened? |
(vignette still) Click to play |
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Slide 23 Why Did It Happen? |
(vignette still) Click to play |
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Slide 24 What Will You Do to Reduce the Risk of Recurrence? |
(vignette still) Click to play |
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Slide 25 How Will You Know the Risk is Reduced? |
(vignette still) Click to play |
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Slide 26 Sensemaking Tools to Learn From Defects |
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Slide 27 Causal Coding: Eindhoven Model5 |
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Slide 28 Root Cause Analysis Example6 |
Root causes
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There are three root causes and root cause classification codes. The first root cause reads: "Temp nurse unclear about procedure," and the classification code is "OK" (Organizational, Knowledge transfer—because the temp nurse was not fully briefed on the hospital's procedures at the start of her shift ) The second root cause reads: "Nurse was busy and distracted," and the classification code is "OM" (Organizational, Management— many regular nurses were on sick-out, due to management's decision to decrease vacation benefits). The third root cause reads: "Nurse sees that unit is A positive," and the classification code is "HEX" (Human, External to the organization— the temps needed help because they were from outside the agency). | |||||||||||||||
Slide 29 CUSP and Sensemaking: Next Steps |
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Slide 30 Summarize and Share Your Findings |
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Slide 31 Communicating the Learning |
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Slide 32 Summary: Sensemaking and Identifying Defects |
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Slide 33 Summary of Sensemaking and Learning From Defects |
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Slide 34 References |
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Slide 35 References |