1. “Use data to shed light, not heat.” Source: Reinertsen JL et al 2007.

2. Needs Analysis 1.Observational techniques 2.Questioning techniques 3.Event-based analyses From Safety at the Sharp End by Flin, O’Connor, and Crichton

3. Makary/Coordination Question

4. “Problem personnel are dealt with constructively by our (local/senior) management” Average: 32% positiveAverage: 21% positive

5. Practicalities of surveys Participation matters Debrief Dig deeper Small-scale surveys work too

6. Never Events & Good Catches

7. Sentinel Event Sentinel events are defined as "an unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof."

8. Table. Never Events, 2011 The National Quality Forum's Health Care "Never Events" (2011 Revision) BC PSLS Clinical Process or Procedure Events Surgical eventsTreatment, Procedure, or Intervention Events Surgery or other invasive procedure performed on the wrong body part Incorrect site, body part or side Surgery or other invasive procedure performed on the wrong patient Incorrect patient Wrong surgical or other invasive procedure performed on a patient Incorrect treatment, process or procedure Unintended retention of a foreign object in a patient after surgery or other procedure Missing or retained object or incorrect surgical count or no surgical count Intraoperative or immediately postoperative/postprocedure death in an American Society of Anesthesiologists Class I patient AHRQ website: permission from the National Quality Forum

9. Joint Commission Wrong-site surgeries 209 Communication Patient Management Clinical Performance

12. Themes at your site Patient Safety Learning System Root Cause Analysis in Surgery Checklist compliance or observation Culture survey or Gallup poll Anything that gives you a glimpse into the need

13. Table discussion: needs analysis What are you seeing? Positive and Negative What are three things that you could focus on at your site? Example: – Debriefing phase of checklist – Teamwork between disciplines – Pockets of disrespect – Some nurses find it hard to speak up – Frustrations with equipment needs