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