More About …Flow Diagramming.pptVIP

More About … Flow Diagramming Why do a Flow Diagram? “Big Picture” perspective Avoids “hindsight” bias (forcing function for sticking with the facts) Makes clear what you know, and what you don’t know Make it easy to do … FIRST, read through the Triage flip book Use tools and techniques that make the process easier (flip charts, sticky notes, brainstorming, “parking lot” for questions, etc.) Walk around the scene of the event, use the equipment, and safely simulate what happened (don’t have a second accident!) The team needs to answer: What happened? Why did it happen? What are you going to do about it (to prevent it from happening again)? Diagram what happened. There are 2 Flow Diagrams (initial and final) Start with either the “what happened” fact/event or at the beginning and work backward* *Beware of hindsight bias Patient Safety - Error Analysis Building the Flow Diagram Outline the “story” with the diagram Use the narrative for the fine detail Add evidence below the event boxes Ask “Why, Why, Why” Example * * Event Reported: A patient in a locked ward was found on the floor in his room with 3rd degree burns to his chest and arm. The patient had been last seen requesting a cigarette. A partially burned posey was still attached to the patient’s wheelchair. Initial Flow Diagram A B C Patient was wearing posey in wheelchair Posey ignited, burns, and breaks Patient falls out of his wheel- chair Patient found burned, laying on the floor Sample Our Example Intermediate Step - Working Diagram Patient was wearing posey in wheelchair Posey ignited, burns, and breaks Patient falls out of his wheel- chair Patient found burned, laying on the floor Why3? What was the ignition source? How was the ignition source obtained? Was this patient a known fire risk? Why was a combustible posey used? Why3? Why was a restraint device used? Why wasn’t a less restrictive device used? ???? HFC-6, HFT-2, HFT-3, HFT-4, HFT-5, HFFS-7, EE-13, EE-14, EE-15, E