WIP based on Emery Roe's 2013 book. See also Dynamics in Action IM-3239 for more on behavior and The Art of the State IM-11962 for more on Grid-Group Cultural Theory

Reliability Policy Management Performance Behavior Politics Culture Safety Resilience Multiscale Complexity Decision Making

Grid-Group Culture applied to Public Management WIP based on Christopher Hood's 1998 book. plus excerpts from Schwartz and Thompson's 1990 Book Divided we stand. See also Managing Mess IM-11581 and FourCultures Blog and Wikipedia Cultural Theory of Risk

Reliability Policy Politics Management Performance Behavior Culture Safety Resilience Grid Group

Simple exposition of going solid article by Cook and Rasmussen 2005 after reading p156 section 4.1 of Modelling in Healthcare by CSMG See also Resilience Cs IM

Health Care Services Patient Flow Performance Clinical Care Work Safety Resilience

Addition of Incident Reporting and Prevention Interventions to a simple error chain of medication errors for patients in hospital IM-10113 

Health Care Medicines Safety Clinical Care

From Margaret Stringfellow's PhD thesis from Nancy Leveson's Engineering a Safer World

Health Care Governance Control Health System Safety Performance

Rich picture version of causal loop diagram for medication errors, showing the importance of reporting, analyzing and fixing knowledge and process errors. Medication errors will tend to grow due to the use of more medications in more complex patients. This is exacerbated by the loss of staff knowledge by turnover and goal erosion in places with harmful errors.

Health Care Medicines Clinical Care Safety Informatics Performance

From PLOS One Article April 2012 Worni, M et al System Dynamics to Model the Unintended Consequences of Denying Payment for Venous Thromboembolism after Total Knee Arthroplasty

Health Care Policy Funding Clinical Care Surgery Quality Safety Performance Unintended Consequences

A simple error chain of medication errors for patients in hospital. Serious medication errors in inpatients with drug orders sometimes result in Adverse Drug Events (ADE) and Deaths. See next IM-646

Health Care Medicines Safety Clinical Care

Columbia loss dynamics from FIg 13.1 Nancy Leveson's Engineering a Safer World Book

Performance Safety Engineering

WHO FBE WIP Hospitals Safe from Disasters

Health Care Built Environment Safety Resilience Hospital

From Nancy Leveson Vioxx Recall Study in CH8 Engineering a Safer World and Couturier's MIT ESD Thesis

Health Care Medicines Safety Performance

Model describes influences different variables on Lessons Learned from Acc/Incidents to maximise "Learning from Incidents" so as to prevent accidents.

Safety Lessons Learned Safety Lessons Learned Accidents Incidents

Model describes influences different variables on Lessons Learned from Acc/Incidents to maximise "Learning from Incidents" so as to prevent accidents.

Safety Lessons Learned Safety Lessons Learned Accidents Incidents

Any and every organization that performs tasks or activities at risk is a system with emergent behavior of a Quality & Safety Culture. There is never a zero state of culture, as every risk or potential risk is met with risk assessment and response through the interactions of the stakeholders.

Quality Safety Risk Culture

Potential Diagnostic Error flows based on Schiff's Diagnostic Error Categories

Health Care Clinical Care Decision Making Safety Diagnosis

Causality Circle

Safety

Based on ED RCA Report Taxonomy and Checklist Form

Emergency Safety Incident Health Care

This Causal Loop seeks to outline the key elements where safety can be improved in a red meat processing plant.

Safety Red Meat Processing Agribusiness Agriculture Systems

Indenpendent Growth

Safety

Model describes influences different variables on Lessons Learned from Acc/Incidents to maximise "Learning from Incidents" so as to prevent accidents.

Safety Lessons Learned Safety Lessons Learned Accidents Incidents

WIP based on Emery Roe's 2013 book. See also Dynamics in Action IM-3239 for more on behavior and The Art of the State IM-11962 for more on Grid-Group Cultural Theory

Reliability Policy Management Performance Behavior Politics Culture Safety Resilience Multiscale

Any and every organization that performs tasks or activities at risk is a system with emergent behavior of a Quality & Safety Culture. There is never a zero state of culture, as every risk or potential risk is met with risk assessment and response through the interactions of the stakeholders. This version extends the model for the Thinking Systemically Session of STIACP.

Quality Safety Risk Culture

Rich picture version of causal loop diagram for medication errors, showing the importance of reporting, analyzing and fixing knowledge and process errors. Medication errors will tend to grow due to the use of more medications in more complex patients. This is exacerbated by the loss of staff knowledge by turnover and goal erosion in places with harmful errors.

Health Care Medicines Clinical Care Safety Informatics

WIP ​Book Summary see blog entry

Organization Psychology Safety Book Edmondson