SLIDE 1
Initiating Incidents
- Many CIs involved a real or potential poor
patient outcome
- Most common
Location of Critical Incident 60 50 40 # of CIs 30 (n=109) 20 - - PowerPoint PPT Presentation
Location of Critical Incident 60 50 40 # of CIs 30 (n=109) 20 - - PowerPoint PPT Presentation
Location of Critical Incident 60 50 40 # of CIs 30 (n=109) 20 10 0 Inpt Outpt NICU ED PICU Other Location Initiating Incidents Many CIs involved a real or potential poor patient outcome Most common Medication error
SLIDE 2
SLIDE 3
Initiating Problems
5 10 15 20 25 30
Sign-off Procedure Discoordination System I ssue Documentation Knowledge gap Evaluation problem Med Error Management Error % of CI with problem
SLIDE 4
Critical Incident Themes
5 10 15 20 Difficult patient Cultural Competence Delivering Bad News Listening Empathy Advocacy Family Communication Percent of CIs with Theme
SLIDE 5
S kills/ Attributes Reinforced by CIs
- CIs often reflect a resident’ s growing
appreciation of a specific professional skill or attribute, e.g.:
– S taying calm – Maintaining focus – Trusting self – Both feeling and controlling grief
SLIDE 6
5 10 15 20 25
Asking for help Other-trust Persistence Vigilance Self-trust Clear Communication Diligence
Attribute Percent of CI s with attribute
S kills/ Attributes Reinforced by CIs
SLIDE 7
S ummary: Most Common CI problems
Problem Percent
- f CIs
Competency Domain(s)
Communication with team, families, or written in chart
59
Com
Patient management or evaluation
44
PC
Medication errors
21
S BP
Knowledge/ skill gap
18
MK
SLIDE 8
Most Common Personal Themes
Personal Themes Percent
- f CIs