1. “Doing it better”

2. Overall Goal
To make the system safer

3. General Principles Safe and Just Culture Consistency and Fairness
Encourages reporting of incidents and safety hazards
Consistency and Fairness
Healthcare providers need to understand how their organization will apply analysis processes and they need to be confident that the structure will consistently be applied
Team Approach
Confidentiality
Team members need to be able to participate honestly without fear of of reprisal
Canadian Incident Analysis Framework 2012 – Canadian Patient Safety Institute

4. Patient

5. Questions about the case?
Any details you would like filled in to help understand the events and the timeline?

6. Analysis - Task Were there specialized skills required for the task?
Were there previous or predicted failures for this process?
Was an up to date protocol available for this process and was it followed?
Was the required information to make decisions available?

7. Analysis – Patient Characteristics
Did the patient have the information that would have assisted in avoiding the incident?
If not, what would have helped?
Did factors like age, sex, meds, allergies, other medical conditions contribute to the incident?
How?
Did any social or cultural factors contribute? How?

8. Analysis - Care Team: provider
Were the education, experience, training and skill level appropriate?
Was fatigue or other health factors an issue?
Was appropriate and timely help or supervision available?
Highlight: Lessons learned for all patients

9. Analysis – Care Team: Supporting Team
Was there a clear understanding of roles and responsibilities?
Was the quality and quantity of communication between team members appropriate?
Were there regular team briefings about important care issues?
Was team morale good? Do team members support each other?

10. Analysis – Organization: Culture
Was everyone comfortable to speak up about safety concerns?
Were incidents considered systems failures and not blamed on individuals?

11. Analysis – Organization: Capacity (resources)
Did scheduling influence the staffing levels or cause stress, fatigue?
Was there sufficient capacity in the system to perform effectively?

12. Analysis – Organization: policies
Were the relevant policies and procedures available/known/accessible?
Were there ‘work arounds’ to the documented policy/procedure?

13. Analysis - Other
Were there any local conditions or circumstances that may have influenced the incident/outcome?

14. Analysis - Equipment Were the displays and controls understandable?
Were the warning labels and reference guides functional and readily visible?
Was the equipment standardized?
Would the users describe the equipment as “easy to use”?

15. Analysis – work environment
Did noise levels interfere with alarms?
Was the lighting adequate?
Was the work area adequate for the task being performed?

16. What can we change to make sure this doesn’t happen again?