After this session you’ll be able to:

1. Describe two patient safety tools used to investigate a safety event.
2. Discuss the importance of obtaining different perspectives of a safety event.
3. Analyze a safety event utilizing patient safety tools.

Why this is important:

Root cause analysis (RCA) is a systematic approach to a safety event that seeks to identify and correct system flaws to prevent the error from recurring. Perioperative leaders need to be well versed in the process of objectively facilitating the investigation and review of multidisciplinary safety events.

Participation of frontline staff, along with leadership support, can bolster the thoroughness of the analysis and the implementation of actionable items. The use of patient safety tools and an immersive hands-on approach in a simulated learning environment helped the speakers understand and address safety events in their facility. Gain a basic understanding of investigation, analysis, identification of the root cause, and development of actionable items to help prevent recurrence of an adverse event.