Introduction (00:00:00)
Title Slide (00:01:54)
Medication Errors (00:02:58)
Organizational Learning: Institute of Medicine Report (00:04:29)
Organizational Learning (00:05:15)
Past Experience (00:06:33)
Event Classification (00:07:22)
Aviation-based Research Questions (00:08:25)
Methods: Sample (00:10:07)
Methods: Data Collection and Analysis (00:10:36)
Results (00:11:10)
Examples (00:12:56)
Medication Flow Chart (00:13:45)
Example 1: Physician Callbacks (00:14:32)
Physician Callbacks: Professional perspectives (00:15:41)
Physician Callbacks: Perceived professional responsibility (00:17:46)
Physician Callbacks: Information Gathering Feedback Channels (00:20:07)
External Review Committee: Nursing (00:27:43)
External Review Committee: Nursing (2) (00:29:58)
External Review Committee: Event Contingencies (00:31:38)
External Review Committee: Nursing (00:32:18)
External Review Committee: System Heuristic (00:33:44)
ERC: Information Gathering (00:35:29)
ERC: Defining Away Dangers (00:35:58)
ERC: Organizational Learning Capacity (00:36:41)
Hospital: Pharmacy Defining Away Dangers (00:42:00)
Hospital: Pharmacy Defining Away Dangers (00:44:30)
Defining Away Dangers: Pharmacy (00:44:38)
Health Policy Implications (00:46:56)
Organizational Learning as a Process (00:50:05)
Questions (00:53:27)
Presentation of Tile (01:24:33)
