Science

Power Hour Breakout

(K3) Patient Safety Science: Introduction to Root Cause Analysis Following a Patient Safety Event

Presenter(s)

• 

  Samantha Crandall, MSN, RN, CPHQ, CPPS

  System Patient Safety Specialist
  Sharp HealthCare

  Nothing to Disclose

This session will introduce tools used to help those responding to patient safety events or those investigating undesirable patient outcomes to best reach a root cause. Patient safety science foundations will be covered, and individual and system failures reviewed. In addition to effectively identifying root and contributing causes, this session will teach participants how to best develop action items directly related to the type of error that occurred to prevent recurrence.

Learning Objectives:

• Use a systemic process to uncover all causal factors and sufficiently investigate each one by asking "why" as many times as necessary
• Describe each of the human error types (skill, rule, knowledge) in the Generic Error Modeling System (GEMS)
• Discuss the driver of non-compliance: perceived burden, perceived risk, co-worker coaching and belief system