Patient Safety Event Analysis
Investigate patient safety events using RCA, FMEA, and other systematic analysis methods to identify contributing factors and develop corrective actions.
Overview
This skill enables systematic analysis of patient safety events. It encompasses root cause analysis, failure mode analysis, contributing factor identification, and corrective action development to prevent recurrence and improve patient safety.
Capabilities
Root Cause Analysis
- Event investigation
- Timeline reconstruction
- Causal factor identification
- Contributing factor analysis
- System issue identification
FMEA
- Process step identification
- Failure mode identification
- Severity assessment
- Occurrence probability
- Detection analysis
Investigation Methods
- Staff interviews
- Chart review
- Process observation
- Equipment analysis
- Environmental assessment
Corrective Actions
- Action development
- Risk mitigation
- Implementation planning
- Effectiveness monitoring
- Sustainability measures
Usage Guidelines
RCA Process
- Identify and report event
- Assemble investigation team
- Gather information
- Reconstruct event timeline
- Identify contributing factors
- Determine root causes
- Develop corrective actions
- Implement and monitor
FMEA Process
- Select process to analyze
- Assemble multidisciplinary team
- Map process steps
- Identify potential failure modes
- Score risk (RPN)
- Prioritize actions
- Implement improvements
- Reassess risk
Documentation Standards
- Comprehensive event reports
- Investigation documentation
- Action tracking logs
- Effectiveness measures
- Lessons learned
Integration Points
Related Processes
- Root Cause Analysis
- Patient Safety Event Reporting
- FMEA Process
- HRO Implementation
Collaborating Skills
- quality-metrics-measurement
- clinical-workflow-analysis
- accreditation-tracer-simulation
References
- Joint Commission RCA framework
- IHI patient safety resources
- AHRQ safety tools
- HRO principles