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.

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

4. Learning Objectives
What
Why
How

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

8. Theory Overview
Ioana Popescu

9. The Big Picture

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

14. Practice
Carolyn Hoffman

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

24. Guest Speaker
Melanie Henderson

25. Discussion