Reminder:  May 7, 2013

 Incident Investigation and Root Cause Analysis Workshop 

This workshop has been developed to reduce the risk of recurrence of preventable patient harm arising from ineffective organizational remediation practices and capabilities, new failure modes and associated patient harm emerging from unrecognized latent conditions, and introducing new system vulnerabilities in responding to errors and accidents.

Workshop Goals – Participants will be able to

• Help their organizations conduct more effective root cause analyses, and learn from unexpected events;
• Redesign clinical processes and systems to reduce the risk of accidental injury; and
• Apply lessons to other systems performance challenges, including health care quality improvement.

 Agenda topics –

• Learning from Unexpected Events
• Root Cause Analysis Briefing
• Human Factors Applications
• Fault Tree and Causal Tree Analysis
• Applied Behavior Analysis