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'Tell the nursing student to attach the oxygen mask and tubing to the green spigot' ... Adapted From John Gosbee, MD, MS. VA National Center for Patient Safety. 2 ' ...
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Patient Safety Interventions John Gosbee, MD, MS VA National Center for Patient Safety John.Gosbee@med.va.gov www.patientsafety.gov Adapted from John Gosbee, MD, MS
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TRIZ and Patient Safety John Gosbee, MD, MS Human Factors Engineering and Healthcare Specialist VA NCPS John.Gosbee@med.va.gov Adapted from Jack Hipple; Innovation-TRIZ
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Title: Application of Human Factors Engineering to Health Care Author: John Gosbee Last modified by: rosenei Created Date: 9/27/2000 6:23:45 PM Document presentation ...
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Human Factors Engineering and Patient Safety Michigan Health & Safety Coalition Annual Conference John Gosbee, MD, MS VA National Center for Patient Safety
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Adapted from John Gosbee, MD, MS. VA National Center for Patient Safety ... tank and put it in the endoscopy cabinet & attach it to the insufflator valve' ...
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John Gosbee, MD, MS. VA National Center for Patient Safety. 23SEP02. Definitions ... Synonyms for our keywords are many, and some hard to 'see' in a sea of text ...
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Red. Red. Red. Blue. Blue. Blue. Yellow. Yellow. Yellow. Green. Green ... 'Tell the nursing student to attach the oxygen mask and tubing to the green spigot' ...
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Held at UM Towsley Center 11/22/02. Webcast to ten sites around state. Registrants = 195 ... Transformation of Root Cause Analysis learning into gains in ...
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RISCHIO CLINICO IN SALA OPERATORIA Maria Teresa Montella Risk management l insieme di azioni complesse messe in atto per migliorare la qualit delle ...
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Human Factors Engineering and Patient Safety Faculty Development ... Knee-jerk vs. HFE-based Remedy. Make 'sure' to use the correct color Adaptor!? Better ...
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Location in our VA NCPS Curriculum Toolkit. Content. Patient ... Air-oxygen flowmeter confusion. Anaesthesia. 2003 Feb;58(2):194-5. http://www.ncbi.nlm.nih.gov ...
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Anaesthesia. 2001 Dec;56(12):1205-6. http://www.ncbi.nlm.nih.gov/ Waite A, Macartney I. ... Anaesthesia. 2003 Feb;58(2):194-5. http://www.ncbi.nlm.nih.gov ...
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... (oops, correct side) ... only causal when there is a pre-existing duty to act. WRONG: The nurse did not check the STAT orders every half hour. CORRECT: ...
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Human Factors Engineering and Patient Safety
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Uncommon: architectural or device changes, engineering solutions. 8/25/09 ... Human Factors and Safety Engineering ... Architectural/physical plant changes ...
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University of Michigan (many times/year) ... Make sure you know your VA or university 'rules' ... Cross-sectional Study of M&M conferences in 4 hospitals ...
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Follow five 'Rules' of thumb (heuristics) for developing root cause statements. 5/8/09 ... Practical rules of thumb. If you're not sure its safe, it's not safe ...
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Understand the definition and scope of patient safety ... Build a good foundation for understanding the systems approach to patient safety ...
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Self-study and Journal Club (e.g., using Web M&M) Homework (spanning weeks or months) ... What is a system and how does it relate to health care? ...
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Patient Safety Initiatives of the VA National Center for Patient Safety ... James Farrier (aviation safety database expert) Narrative is key ...
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Designing things or processes to fit human abilities and limitations ... tank and put it in the endoscopy cabinet & attach it to the insufflator valve' ...
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VA National Center for Patient Safety and Affiliates. VA ... Swift and Long Term Trust 'Selling the Curriculum' to Peers and Leadership for Lasting Change ...
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... questions on diet, lifestyles, medications over the counter medications, herbs, ... Tools continued ' ... Tools. ...
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... factors engineering on patient-controlled analgesia (PCA) administration setup ... engineering to the design of medical equipment: Patient-controlled analgesia. ...
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'Location' in the Curriculum Toolkit. Alternative ... George Carlin. The Absurd Way We Use Language A Decision Making Tool (SAC) ...
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... (FMEA) - reliability engineering for US Military (1949) to determine effect of ... After quickly reviewing the chart, he ordered a 2 unit stat blood transfusion ...
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... nursing student to attach the oxygen mask and tubing to the green spigot' ... 5 cases per month from medicine, surgery-anesthesia, OB/GYN, pediatrics, psychiatry ...
