Morbidity & Mortality to Amazing and Awesome · Simplify/standardize Less effective Reminders Rules & Policies Education & training-+ Activity 4 Identify action items ... Analyze

Preventable

Adverse Lessons

You must be primarily involved

Identify

Analyze

Present

Discuss

Action

System issues

Activity 3Analyze your case for system issues

NOTE - M&M is confidential and NO identifying features of the case

Preventable

Adverse Lessons

You must be primarily involved

Identify

Analyze

Present

Discuss

Action

Present10min Set up

10min Analyse

10min Discuss & Action Items

DiscussCognitive issues

System issues

Action items

Bottom lineACTION

More effectiveForcing function

Automation

Simplify/standardize

Less effectiveReminders

Rules & Policies

Education & training

-

+

Activity 4Identify action items

NOTE - M&M is confidential and NO identifying features of the case

Preventable

Adverse Lessons

You must be primarily involved

Identify

Analyze

Present

Discuss

Action

SlidesInvite everyone

involved

Amazing and AwesomeRounds

Activity 5Identify an amazing and awesome case, analyze for one

cognitive or system deviance

NOTE - M&M is confidential and NO identifying features of the case

Preventable

Adverse Lessons

You must be primarily involved

Identify

Analyze

Present

Discuss

Action

Identify the constellation

Be Amazing and

Awesome with NOSM

@robertohle@sarah_mcisaac

robert.ohle@gmail.comsarah.mcisaac@gmail.com