ROOT CAUSE ANALYSIS AND MEDICAL ERROR PREVENTION

Course overview

THE TERM "MEDICAL ERROR" ENCOMPASSES DIVERSE EVENTS THAT VARY IN MAGNITUDE AND CAN POTENTIALLY HARM THE PATIENT. ACCORDING TO THE 2019 WORLD HEALTH ORGANIZATION (WHO) PATIENT SAFETY FACTSHEET, ADVERSE EVENTS DUE TO UNSAFE PATIENT CARE ARE AMONG THE TOP 10 CAUSES OF DEATH AND DISABILITY WORLDWIDE. HOWEVER, IT IS ESSENTIAL TO UNDERSTAND THAT HEALTHCARE DELIVERY INVOLVES MULTIPLE VARIABLES IN A DYNAMIC ENVIRONMENT, WITH MANY CRITICAL DECISIONS MADE QUICKLY. AS SUCH, THE HEALTHCARE SYSTEM CANNOT IMPLEMENT RIGID PROTOCOLS USED BY OTHER HIGH-RISK INDUSTRIES, SUCH AS AVIATION. REDUCING MEDICAL ERRORS REQUIRES A MULTIFACETED APPROACH AT VARIOUS LEVELS OF HEALTHCARE. IN THE EVENT OF A SENTINEL OCCURRENCE OR ADVERSE PATIENT OUTCOMES, A THOROUGH EVALUATION IS WARRANTED TO PREVENT SUCH EVENTS. ROOT CAUSE ANALYSES PROVIDE A METHOD OF EVALUATION FOR THESE SITUATIONS SO THAT A SYSTEM-BASED INTERVENTION CAN BE IMPLEMENTED RATHER THAN BLAMING INDIVIDUAL PROVIDERS. THIS ACTIVITY REVIEWS THE ROOT CAUSE ANALYSIS PROCESS IN MEDICAL ERROR PREVENTION. THE COURSE HIGHLIGHTS THE INTERPROFESSIONAL TEAM'S ROLE IN PERFORMING THIS ANALYSIS TO PREVENT MEDICAL ERRORS AND IMPROVE CLINICAL OUTCOMES.