Patient Safety and Quality Improvement
 Modules  Module 4: The “Analysis” of Medical Error, and Implementation
1. Introduction to Course
2. History of Patient Safety
3. The Science of Human Error
4. The Analysis of Medical Error
5. Evidence-Based Medical Practice
6. Communication and Information Transfer
7. Adverse Patient Outcomes
8. The Role of the Patient and Family
9. Environmental Safety in the Medical Setting
10. Safe Medical Practice In Ambulatory Settings

Common Root Cause Analyses (RCA) Pitfalls

  • 3 separate studies have found similar vulnerabilities in RCAs
    • GE occupational injury investigations
      • Heavy focus on problems that analysts see as fixable such as policy and training issues
    • “Field Guide” handbook by Dekker
      • People focus on specific event, not the broader “type” of event
      • Comfortable illusion that “fixing” the person solves the problem
    • Initial analysis of RCAs coming into NCPS
      • Common: violation of policy, lack of training, inattention
      • Uncommon: architectural or device changes, engineering solutions
 
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