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

Rules for an Effective Root Cause Analysis (Gosbee, 2004)

Rule 1. Clearly show the cause and effect relationship.

  • If you eliminate or control this root cause/contributing factor, will you prevent or minimize future events?
  • WRONG: A resident was fatigued.
  • CORRECT: Residents are routinely scheduled for 80 hour work weeks; as a result, the fatigued residents are more likely to misread instructions, which led to an incorrect tube insertion.
 
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