Patient Safety – Rush Emergency Medicine

Root Cause Analyses and Actions

Summary of the process What follows are steps for completing a root cause analysis. We’ll go into more detail for these in the text following the table. Much of this came out of the work of Sydney Dekker, who used it to evaluate airplane crashes. It applies well here to medicine as well. Event, hazard…

Morbidity and Mortality Conferences

Dec 6, 2020RahulQuality & SafetyMorbidity and Mortality, Patient Safety, Quality Improvement

Or Understanding “Human Error” Humans make mistakes. Any system that depends on perfect performance by humans is doomed to failure. In fact, the risk of an accident is more a function of the complexity of the system than it is the people involved. Humans are not the weak link in a process. We are a…