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Declining D<br />

Revenue,<br />

Competition…<br />

Why did that happen?<br />

Loss <strong>of</strong> resilience.<br />

C<br />

New facility planned<br />

Cost cutting<br />

Focus on efficiency<br />

Normalized<br />

risk; unsafe<br />

behavior<br />

B<br />

Time pressure,<br />

> interruption,<br />

unworkable<br />

procedure,<br />

inadequate #<br />

scanners..<br />

Heightened<br />

A<br />

potential for an<br />

adverse event<br />

Clinical Space<br />

70<br />

NPSF Pr<strong>of</strong>essional Learning Series<br />

May 31, 2012

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