Patient Safety

Panel 18 - (INTERACTIVE) Incident Investigation without Shame and Blame: Just Handling of Whoppers and Whoopsies

4:45 PM - 6:00 PM
Location: Room W181

Session Type: Panel
1.25 AMA PRA Category 1 Credits™
1.5 MDCB Credits

This session will address how attendees can operationalize incident investigations in their clinic in a sensitive manner, so as to be fully supportive of their staff and faculty, but also to be fully dedicated to getting to zero harm.

Understanding Why Whoppers and Whoopsies Happen: This talk will address common cognitive biases that contribute to error in the clinic, and explain how person factors, system factors, patient factors can converge to hinder quality decision making and judgments.

Building a Just Investigation Team: This will focus in on who the best team members are to be part of incident investigations. What personality traits will best serve them in this role? How does professional role influence the quality of the information they can uncover? The emphasis will be on providing support to those involved as well as understanding the event fully.

Choosing your words carefully: This portion of the session will cover specific incident investigation techniques. Attendees will learn how to use the 5 whys, London protocol, and humble inquiry to respectfully and compassionately perform a quality incident investigation

The importance of Follow up and Change in Building Resilience: this portion of the session will discuss how staff and faculty can stay informed about the positive changes that came about because they participated in incident reporting. It is vital for the recovery of staff and faculty after any event of note to be able to tangibly see positive change in their organization. Effective means to achieve this will be taught.

Learning Objectives:


Jean Moran, PhD

University of Michigan

University of Michigan: Professor: Employee

AAPM: Travel Expenses;
Blue Cross Blue Shield of Michigan: Research Grants;
Modus Medical Devices: gels for research applications;
NIH: Research Grants;
Varian Medical Systems: Research Grants

AAPM: Chair: I serve the AAPM as: Chair of the Therapy Physics Committee, Chair of the Work Group on Task Group Review Streamlining and Chair of Work Group on RO-ILS.

Jean Moran, PhD is Professor and Co-Director of the Physics Division in the Department of Radiation Oncology and the Assistant Director of the Michigan Radiation Oncology Quality Consoritum at the University of Michigan. She has been a champion for patient safety for many years and has authored and co-authored a number of guidance documents for ASTRO and AAPM. She advocates for the use of formal risk-based analysis methods in healthcare. She is a member of ASTRO's Multi-disciplinary Quality Assurance Subcommittee and chairs the AAPM Work Group on Radiation Oncology Incident Learning and the Therapy Physics Committee. She is also a co-chair of the Radiation Oncology - Safety Stakeholders Initiative. She is active in clinical care, teaching, and research.


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Panel 18 - (INTERACTIVE) Incident Investigation without Shame and Blame: Just Handling of Whoppers and Whoopsies

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Send Email for Panel 18 - (INTERACTIVE) Incident Investigation without Shame and Blame: Just Handling of Whoppers and Whoopsies