Presenter

Amy Graske is a Senior Human Factors Engineer at Froedtert Health in Milwaukee, WI. She provides consultative services to a broad range of projects to improve patient safety, as well as guides teams in practical application of human factors principles. Amy is experienced in applying human factors principles to improvement work through roles in consulting and facility design. She holds a Master’s in Industrial Engineering from University of Wisconsin- Madison.

In a proactive patient safety program, there are many opportunities to apply macroergonomic methods to sustainably address widespread safety hazards. While great progress has been made in the broad use of systems-based review frameworks such as RCA2, additional systems analyses and tools can add perspective to the issue, and assist in identifying and addressing interactions and interdependencies in system elements. Amy will illustrate how the copious data collected through these methods were summarized in a way to retain the complexity of the context surrounding subcutaneous insulin administration errors in the acute care setting. By distilling this complex data to tell a story, the diabetes team was able to implement multifaceted interventions that brough needed standardization while adapting to the nuances of clinical differences among patients.