Healthcare Failure Mode and Effect AnalysisSM Edward J. Dunn, MD, MPH VA National Center for Patient Safety edward.dunn@med.va.gov www.patientsafety.gov
'Blow-up' of One Line. Unwanted alarms on floor are reduced by 75% within 30 days of implementation ... Reduce unwanted alarms by: changing alarm parameter to ...
Healthcare Failure Mode and Effect AnalysisSM. Edward J. Dunn, MD, MPH ... parameter to fit patient physiological condition and replace electrodes with ...
Healthcare Failure Mode and Effect AnalysisSM Edward J. Dunn, MD, MPH VA National Center for Patient Safety edward.dunn@med.va.gov www.patientsafety.gov
Human Factors Engineering and Patient Safety Faculty Development ... Knee-jerk vs. HFE-based Remedy. Make 'sure' to use the correct color Adaptor!? Better ...
... (FMEA) - reliability engineering for US Military (1949) to determine effect of ... After quickly reviewing the chart, he ordered a 2 unit stat blood transfusion ...
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 ...
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' ...
VA National Center for Patient Safety and Affiliates. VA ... Swift and Long Term Trust 'Selling the Curriculum' to Peers and Leadership for Lasting Change ...
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' ...
Letting learners choose to choose. autonomy and control in online learning ... the subject is always in the position of concsious that someone awaits for the ...
NYC Subway Accidents 1996. NYC Subway accidents in 1996 ... Investigators: 'good fortune that no one was killed' 1963 collision sinking ferry Verrazano ...
Cross-coverage is a way of life for most physicians, especially residents ... but he has a large right heel ulcer with surrounding erythema, probing through to bone. ...