Welcome to No Harm Done Episode 15 hosted by Cathy Balding and Cathy Jones, from Melbourne, Australia.
In this episode we get proactive about Risk Management in RM Part 2 – ‘Safety 2’ – as our Quality Quandary and TLDR. What’s it all about? In Quality Hacks, Balding describes how to develop your story using the ‘Pixar Pitch’ and Jones has a gentle rant about email addresses. The Point considers consumer vulnerability. And more! What would you like us to talk about next? Send us a message below!
0.00 QUALITY QUANDARY: Safety 2. What is it – and why do you need to know?
Refs:
From Safety-I to Safety-II: A White Paper Professor Erik Hollnagel University of Southern Denmark, Institute for Regional Health Research (IRS), Denmark Center for Quality, Region of Southern Denmark Professor Robert L Wears University of Florida Health Science Center Jacksonville, United States of America
Paul Plsek, Understanding the System You Are in Is Key to Improving It HealthcarePapers 17(1) July 2017 : 38-43.doi:10.12927/hcpap.2017.25335
Jeffcott SA, Ibrahim JE, Cameron PA
Resilience in healthcare and clinical handoverBMJ Quality & Safety 2009;18:256-260.
20:30 THE POINT: How vulnerability changed the perspective of one nurse – and why knowing too much can make you feel more vulnerable – not less.
Ref: Schuler, M. (2019). Changing Roles, Changing Perspectives—Vulnerability as a Patient. Journal of Patient Experience, 6(1), 5–6. https://doi.org/10.1177/2374373518769662
26:27 TOO LONG DIDN’T READ (TLDR): We deconstruct human factors as a key component of Safety 2. There are a few TLDRs in this episode, all under the human factors umbrella.
Refs:
Russ AL, Fairbanks RJ, Karsh B, et al The science of human factors: separating fact from fiction. BMJ Qual Saf 2013;22:802-808.
Leape LL. Error in Medicine. JAMA. 1994;272(23):1851–1857. doi:10.1001/jama.1994.03520230061039
Doug Bonacum (IHI) Error Reduction – Hierarchy of Controls:
http://app.ihi.org/FacultyDocuments/Events/Event-2883/Presentation-15021/Document-11934/Presentation_3_2_Human_Factors.pdf
50:31 QUALITY HACK: In this episode we discuss how to create your Pixar Pitch – and why! Plus Jones’ beef about email addresses.
Ref: Pixar Pitch
http://www.workingdifferently.org/working-differently-blog/the-pixar-pitch-telling-your-story-crisply-and-with-clarity-in-order-to-compel-action