Learning from Mistakes: A Root Cause Analysis Case Study

Description

To effectively learn from health care errors and prevent their recurrence, we must understand their root cause. Root cause analysis (RCA) looks beyond the individuals involved and seeks to understand the causes and context in which the incident occurred through a process of data collection and cause charting. Learn how to conduct an RCA with your team.

Pharmacist Learning Objectives

At the completion of this application-based activity, participants will be able to:

  1. Explain the root cause analysis (RCA) process using predetermined steps and associated tools.
  2. Describe the importance of conducting an RCA following a sentinel event.
  3. Prepare an action plan from the RCA which includes risk-reduction strategies, communication, and implementation strategies as well as ways to measure effectiveness.
  4. Identify and address latent failures in the system discovered during an RCA.
  5. Describe the difference between high-leverage and low-leverage safety strategies.

Technician Learning Objectives

At the completion of this application-based activity, participants will be able to:

  1. Explain the root cause analysis (RCA) process using predetermined steps and associated tools.
  2. Describe the importance of conducting an RCA following a sentinel event.
  3. Prepare an action plan from the RCA which includes risk-reduction strategies, communication, and implementation strategies as well as ways to measure effectiveness.
  4. Identify and address latent failures in the system discovered during an RCA.
  5. Describe the difference between high-leverage and low-leverage safety strategies.
 
 
 
Speakers:
Karen
Karen Ryle,
Massachusetts General Hospital
 
Donna
Donna Horn,
Director
Institute for Safe Medication Practices
 
Learning Level: Level 2
Pathway: Meeting Highlights Video on Demand
Track: Pharmacy Law and Regulations
Session Time Slot(s): 
Date: 
Monday, March 27
Time: 
10:00 AM - 12:00 PM
Room: 
Moscone - Esplanade 303
ACPE Pharmacist: 0202-0000-17-089-L05-P
CEUs Pharmacist: .2
ACPE Pharmacy Technician: 0202-0000-17-089-L05-T
CEUs Pharmacy Technician: .2
Activity Type:
Application-based