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

Unfolding story based on Emery Roe's 2013 book Making the Most of Mess 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

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

Grid-Group Culture applied to Public Management 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

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.

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

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.

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.

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

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

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

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

WIP ​Book Summary see blog entry Also Chuang2009 ISDC P1127 paper, Newman2017 and Edmondson2014 papers

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

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.

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.

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

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.

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

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

WIP ​Book Summary see blog entry Also Chuang2009 ISDC P1127 paper, Newman2017 and Edmondson2014 papers

Based on ED RCA Report Taxonomy and Checklist Form

WHO FBE WIP Hospitals Safe from Disasters

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