The Constellation Diagram A deeper dive

Welcome

Ioana Popescu Nadine Glenn Arlene Pelley Erin Pollock

Program Overview

• Welcome and Introduction

• Constellation Diagram

o Theory

o Case

o Tools – you already have it!

• Q&A

• Participant Presentation and Discussion

• Wrap up and Poll

Questions/ comments: CHAT

Learning Objectives

What

Why

How

5

Introducing: WebEx

4-Sep-13 5

Be prepared to use: - Chat - Raise Hand - Large arrow - Emoticons

About YOU

About You

How familiar are you with the Constellation Diagram?

Never heard of it ………..……X……………………………X……....….. Can’t analyze without it

Theory Overview

Ioana Popescu

The Big Picture

What

Why

- Systematic, structured, and at the same time organic process

- Focus with more precision on where the greatest risks are

- Identify & visualize relationships, interconnections, influences among contributing factors

- Analysis is more thorough and credible (p. 24)

- Avoid cognitive traps (p. 25)

Who

Depends on the type of analysis

• Comprehensive—The entire analysis team participates

• Concise—Usually the analysis lead

• Multi-Incident—Team.

Supporting tool: Guiding Questions (Appendix G, Canadian Incident Analysis Framework)

How

5 Steps • Step 1: Describe the incident

• Step 2: Identify potential contributing factors

• Step 3: Define inter-relationships between and among potential contributing factors.

• Step 4: Identify the findings

• Step 5: Confirm the findings with the team

Practice

Carolyn Hoffman

Case: Wrong Site Surgery

Review

• Scenario

• Timeline

• Additional information

Case: Wrong Site Surgery

Prep Work

- What do we need to know before the team meeting?

Team meeting

- The largest Comprehensive Analysis Team Meeting ever!

- Benefits/risks of a team meeting

- Tips for success

Case: Wrong Site Surgery

Diagramming

Case: Wrong Site Surgery

Next Steps – engage & strive for highest level of effectiveness for recommendations

Case: Wrong Site Surgery

Resources

http://www.globalpatientsafetyalerts.com/English/Pages/default.aspx

Case: Wrong Site Surgery

Resources

Case: Wrong Site Surgery

Resources

Case: Wrong Site Surgery

Resources

http://www.saferhealthcarenow.ca/EN/Interventions/SafeSurgery/Pages/SurgicalSafetyChecklist.aspx

Q&A

Guest Speaker

Melanie Henderson

Discussion