June 17, 2020 | Barb Carr

Patient Safety RCA: Prevention, Not Punishment

Every procedure performed by a healthcare worker carries a certain degree of inherent risk, which might lead to a healthcare adverse event. When an adverse event occurs in patient safety, quite often the workers shoulder the blame. However, for any real and lasting solution to the problem, we need to focus on prevention, not punishment. This involves the right patient safety rca tools.

Patient safety root cause analysis tools guide the investigator in:

Determining what happened by collecting all the evidence to eliminate investigator bias.
Ensuring all mistakes and errors are identified.
Determining why it happened by analyzing those mistakes and errors for root causes.
Implementing effective correction actions.

Root cause analysis is an essential tool for a positive safety culture and elimination of blame in healthcare.

TapRooT® Root Cause Analysis for Patient Safety

TapRooT® Root Cause Analysis is ideal for patient safety because it incorporates all the tools above. Further:

TapRooT® is supported and inclusive of decades of human factors research.
TapRooT®’s organizational tool, SnapCharT®, helps investigators identify gaps in the sequence of events that led to an incident. No stone goes unturned and investigators don’t jump to wrong conclusions.
TapRooT® guides investigators to identify hazards and failed safeguards and their potential influence.
TapRooT®’s Human Performance Troubleshooting Guide provides expert guidance to analyze human errors.
The Root Cause Tree® Diagram takes the investigator beyond his/her own knowledge with the Root Cause Tree® Dictionary providing a quick reference and expert information for determining all root causes.

To learn how to systematically improve the quality of healthcare at your facility, please join us on July 1, 2:00 pm EST for our