Overview/Summary:
In this second installment surrounding medical error prevention, Patient Harm Occurred: What Now discusses the approach when encountering a potential medical error
including recommendations and elements comprising a root cause analysis (RCA), tools typically used and available when performing a root cause analysis and ultimately reasons for process improvement failure.
Educational Objectives:
• Verbalize 3 elements of a root cause analysis
• Differentiate between tools used in performing a root cause analysis
• Recall a reason for process improvement failure