The constellation diagram a deeper dive
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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.
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The constellation diagram a deeper dive
- 1. The Constellation Diagram A deeper dive
- 2. Welcome Ioana PopescuNadine GlennArlene Pelley Erin Pollock
- 3. 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
- 5. 5 Introducing: WebEx 4-Sep-13 5 Be prepared to use: - Chat - Raise Hand - Large arrow - Emoticons
- 6. About YOU
- 7. About You How familiar are you with the Constellation Diagram? Never heard of it ………..……X……………………………X……....….. Can’t analyze without it
- 10. What
- 11. 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)
- 12. 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)
- 13. 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
- 15. Case: Wrong Site Surgery Review • Scenario • Timeline • Additional information
- 16. 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
- 17. Case: Wrong Site Surgery Diagramming
- 18. Case: Wrong Site Surgery Next Steps – engage & strive for highest level of effectiveness for recommendations
- 19. Case: Wrong Site Surgery Resources http://www.globalpatientsafetyalerts.com/E nglish/Pages/default.aspx
- 20. Case: Wrong Site Surgery Resources
- 21. Case: Wrong Site Surgery Resources
- 22. Case: Wrong Site Surgery Resources http://www.saferhealthcarenow.ca/EN/Interventio ns/SafeSurgery/Pages/SurgicalSafetyChecklist.aspx
- 23. Q&A
- 25. Discussion