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
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.
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
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
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.
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.
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.
