Jove
Visualize
Contact Us
JoVE
x logofacebook logolinkedin logoyoutube logo
ABOUT JoVE
OverviewLeadershipBlogJoVE Help Center
AUTHORS
Publishing ProcessEditorial BoardScope & PoliciesPeer ReviewFAQSubmit
LIBRARIANS
TestimonialsSubscriptionsAccessResourcesLibrary Advisory BoardFAQ
RESEARCH
JoVE JournalMethods CollectionsJoVE Encyclopedia of ExperimentsArchive
EDUCATION
JoVE CoreJoVE BusinessJoVE Science EducationJoVE Lab ManualFaculty Resource CenterFaculty Site
Terms & Conditions of Use
Privacy Policy
Policies

Related Experiment Videos

Learning from unexpected events: a root cause analysis training program.

Stormy C Sweitzer1, Michael P Silver

  • 1University of Utah, USA. stormita@yahoo.com

Journal for Healthcare Quality : Official Publication of the National Association for Healthcare Quality
|May 23, 2007
PubMed
Summary
This summary is machine-generated.

Related Concept Videos

You might also read

Related Articles

Articles linked to this work by shared authors, journal, and citation graph.

Sort by
Same author

Implementation and Assessment of a Novel Interprofessional Educational Initiative in the Medical Intensive Care Unit: A Mixed-Methods Evaluation.

ATS scholar·2026
Same author

Causes of unplanned hospital admissions: implications for practice and policy.

Home healthcare nurse·2010
Same author

Statewide identification of adverse events using retrospective nurse review: methods and outcomes.

Journal of nursing measurement·2008
Same author

Improved clinical outcomes with utilization of a community-acquired pneumonia guideline.

Chest·2006
Same author

Improving health care systems performance: a human factors approach.

American journal of medical quality : the official journal of the American College of Medical Quality·2004

Effective accident investigation and root cause analysis in healthcare requires specialized training. This workshop provides essential skills for healthcare professionals to conduct thorough analyses, moving beyond operator errors to address systemic issues.

Area of Science:

  • Healthcare Systems Analysis
  • Patient Safety
  • Organizational Learning

Background:

  • Accident investigation and root cause analysis (RCA) in complex systems, particularly healthcare, demand specialized training.
  • Inadequate training leads to incomplete analyses, often focusing on easily manageable factors like operator errors, neglecting organizational contributions.
  • Healthcare traditionally attributes errors to personal accountability, hindering systemic improvement.

Purpose of the Study:

  • To outline a comprehensive incident investigation and root cause analysis workshop tailored for healthcare professionals.
  • To address the critical need for enhanced analytical skills in healthcare settings.
  • To evaluate participant feedback on the developed training program.

Main Methods:

Related Experiment Videos

  • Development of a specialized workshop on incident investigation and root cause analysis.
  • Targeting healthcare professionals across diverse settings in Utah and Nevada.
  • Collection and review of participant feedback to assess training effectiveness.

    • Main Results:

    • The workshop provided a structured approach to incident investigation and RCA for healthcare professionals.
    • Participant feedback indicated the training enhanced their understanding of systemic factors in errors.
    • The program successfully engaged professionals from various healthcare environments.

    Conclusions:

    • Appropriate training is crucial for effective accident investigation and root cause analysis in healthcare.
    • The developed workshop addresses a significant gap in healthcare professional development for patient safety.
    • Further implementation and evaluation of such training are recommended to improve healthcare system safety.