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

Root Cause Statements and Interventions (Actions)

  • These activities are intertwined
  • Making root cause statements accurate and precise is best pathway to effective actions
    • Similar to Diagnosis – Treatment
    • Address why something occurred, not who is responsible
    • Follow five “Rules” of thumb (heuristics) for developing root cause statements
 
Copyright © University of New Mexico
Health Sciences Library and Informatics Center
Learning Design Center