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

1. Identify and report event
2. Assemble investigation team
3. Gather information
4. Reconstruct event timeline
5. Identify contributing factors
6. Determine root causes
7. Develop corrective actions
8. Implement and monitor

FMEA Process

1. Select process to analyze
2. Assemble multidisciplinary team
3. Map process steps
4. Identify potential failure modes
5. Score risk (RPN)
6. Prioritize actions
7. Implement improvements
8. 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