The purpose of this group is to review regional critical incidents in 245D settings and evaluate the systemic influences that contribute to them. The group will make recommendations for level 3 change to DHS’s Culture of Safety Action Group to help organizations move from a culture of fear to a culture of safety.
- Review data within St Louis County using the ‘systemic critical incidents review model’. Critical incidents include elopement, medication error, service termination, staff sleeping, wheelchair safety, COVID, and prone restraint.
- Review top 2 systemic themes within each incident type. Systemic themes include proscribed practice, cognition, procedural drift, service availability, fatigue, ect.
- Develop recommendations and submit to Action Group
