Pawlicki - Causal Analysis · 2015. 2. 13. · Causal Analysis Todd Pawlicki. Just Culture...
Transcript of Pawlicki - Causal Analysis · 2015. 2. 13. · Causal Analysis Todd Pawlicki. Just Culture...
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Causal AnalysisTodd Pawlicki
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Just Culture
Reporting Culture
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Causal Analysis
Equipment
Organization
People
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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
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Youtube: Dan Ariely asks, Are we in control of our decisions?
We are controlled by our biases
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We are controlled by our biases
Youtube: Dan Ariely asks, Are we in control of our decisions?
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Youtube: Dan Ariely asks, Are we in control of our decisions?
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The Incident
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Patient JP was treated to a larger volume than necessary because the MR scan wasn’t fused before the plan was completed.
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Primary Radiation Oncologist
Covering Radiation Oncologist
Dosimetrist
IT
Operations Manager
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What HappenedText goes here
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Why It HappenedText goes here
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RecommendationsText goes here
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ImplementationText goes here
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For Each Group
Moderator
Note Taker
Story Teller