Causal AnalysisTodd Pawlicki

Just Culture

Reporting Culture

Causal Analysis

Equipment

Organization

People

5 sec to find the lung tumor on the CT scanGorillas in our midst: sustained inattentional blindness for dynamic events – Simons et. al. – Perception, 1999, 28(9), p1059

Youtube: Dan Ariely asks, Are we in control of our decisions?

We are controlled by our biases

We are controlled by our biases

Youtube: Dan Ariely asks, Are we in control of our decisions?

Youtube: Dan Ariely asks, Are we in control of our decisions?

The Incident

Patient JP was treated to a larger volume than necessary because the MR scan wasn’t fused before the plan was completed.

Primary Radiation Oncologist

Covering Radiation Oncologist

Dosimetrist

IT

Operations Manager

What HappenedText goes here

Why It HappenedText goes here

RecommendationsText goes here

ImplementationText goes here

For Each Group

Moderator

Note Taker

Story Teller