Professional Documents
Culture Documents
ReviewGroup
and reflect on what
has been discussed
Individually(post its)
In your groups
Data must be
Accurate
Reliable
Unbiased
Well presented
Root Cause
A Simple Fact
YOU CANT MAKE THE RIGHT DECISION WITH A HIGH LEVEL OF
UNCERTAINTY!
Questioning Skills:
Ask the RIGHT people
Ask a broad audience
OPERATORS and SUBJECT EXPERTS
Generalist
Assess Risk
What is Risk?
Risk is the PROBABILITY of harm and the SERVERITY of HARM
Risk Identification?
What can actually go wrong? ?
Risk Analysis
What are the possible consequences(SERVERITY) of harm to the
PATIENT and the BUSINESS?
Risk Analysis
After every Risk Analysis
Take time out
Ask yourself DOES THIS FEEL RIGHT
Professionally
Morally
Ethically
Beware of the Management Hat
Risk Evaluation
Comparison of risk vs. criteria
Assign PROBABILITY and SERVERITY
May be quantitative or qualitative
Risk Control
Is the risk unacceptable?
What can be done to
Reduce risk?
Eliminate risk?
Must be PROPORTIONATE!
Risks
Benefits
Resources
Risk Reduction
Mitigating SEVERITY
Reducing PROBABILITY
Increasing DETECTABILITY(CARE!) ( !)
and then RISK ACCEPTANCE
FinallyALWAYS BE
SYSTEMATIC
Look at symptoms
Get good quality data
Analyze and understand
Consult others
Problem statement
Investigate and risk assess
DECISION!
Dont worryits not your fault. Youve been educated that way
Essential Messages
Remember, our brains are designed for speed not accuracy