https://padlet.com/postgraduate_futures/f52cilv3ut0djbws en-us 2021-03-29 02:11:55 UTC 2026-01-30 07:53:56 UTC hello@padlet.com https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2005869991 feedback from the errors is often not communicated well in many of the settings.As a manger discussing the system failure ,consequences and actions taken to prevent such failures will have great impact .]]> 2022-01-21 22:25:45 UTC https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2005869991 https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2014374835 2022-01-26 19:28:55 UTC https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2014374835 https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2018983017 Before participating in a root cause analysis, the members must have training (such as an e-learning module) in the fundamentals of human factors and ergonomics. ]]> 2022-01-29 08:18:48 UTC https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2018983017 https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2019550108 Knowing that this single approach only looks at one event at one location, impacts on the institutions ability to learn and develop from the errors that occur. As a manager, researching other institutions errors and their outcomes will improve outcomes within the institution. It gives a greater range of knowledge, skills and tools to use while investigating errors especially within small institutions.]]> 2022-01-30 00:22:06 UTC https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2019550108 https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2019610362 Amanda
Instead of seeking an individual at the end of the system failure to blame the system that the individual operates in and the circumstances that the system forces an individual into should be examined and causation at this level considered so that the fix is applied at the right point(s).]]> 2022-01-30 03:27:36 UTC https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2019610362 https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2019654416 //Sissa]]> 2022-01-30 05:39:07 UTC https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2019654416 https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2019654905 Specially trained teams lead the process with staff who come from multidisciplinary roles and who are not directly involved in the specific scenario.
//Sissa]]> 2022-01-30 05:40:35 UTC https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2019654905 https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2020669441 Invite plurality of causes and encourage broad consideration by renaming it Root Causes Analyses & Action.
Bec]]> 2022-01-31 06:19:05 UTC https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2020669441 https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2020670322 Adopt and follow a standardised methodology for design and implementation, which starts with reviewing the last RCA to see what has changed.
Bec]]> 2022-01-31 06:20:01 UTC https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2020670322 https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2020671652 As part of the RCA methodology, invite an impartial facilitator who will not buy-in to politics and who is capable of redirecting the discussion when needed.
Bec]]> 2022-01-31 06:21:36 UTC https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2020671652 mrabbattista https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2024443676 We have seen in Annie’s video from the current module that “problem of too many hands” such as equipment design can be addressed by organisations with strong leadership.]]> 2022-02-01 23:49:08 UTC https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2024443676 ashleighmchugh https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2031142240 I agree that all participants on an RCA team should be provided with education and training.
- Ash McHugh]]> 2022-02-06 05:18:43 UTC https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2031142240 ashleighmchugh https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2031142545 Establish executive 'buy in' early to ensure that the 'bigger issues' can be successfully implemented ]]> 2022-02-06 05:19:31 UTC https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2031142545 ashleighmchugh https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2031143812 In my facility, the DONM, DMS and GM need to 'sign off' on the recommendations. If a recommendation is perceived to be 'too hard' (usually anything to do with staffing) when it doesn't get approved - deemed 'not achievable.' This is very frustrating as the team put a significant amount of work in to identify the root cause and influencing factors that have led to the recommendation. ]]> 2022-02-06 05:22:23 UTC https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2031143812 https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2031171294 I think that mangers could start by actually giving the feedback to staff, especially in areas where the original incident took place. Then, possibly as a team, the unit could deconstruct the results and pick up the areas that they feel they could collectively improve in and an education plan could be made. It is rare in my experience that the results of root cause analyses are shared with staff at the 'sharp end' so it would be helpful to actually know what an investigation found in the first instance.]]> 2022-02-06 06:29:55 UTC https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2031171294 https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2031277651 Reassuring staff that the RCA is aimed at identifying gaps in practice to ensure there is safety and not towards the individual will go a long way in eliminating the blame culture. ]]> 2022-02-06 10:02:35 UTC https://padlet.com/postgraduate_futures/f52cilv3ut0djbws/wish/2031277651