Medication Safety: Incident Analysis and Proactive Risk Assessment
Thursday, January 11, 2018 and Friday, January 12, 2018
This 1.5 day workshop provides healthcare practitioners with background theory and hands-on practice in incident analysis (root cause analysis, RCA) and proactive risk assessment using failure mode and effects analysis (FMEA)
Day 1: Incident Analysis - Root Cause Analysis (RCA)
The program begins with an overview of the system approach in the management of error and introduction to human factors engineering principles. RCA is a tool to help investigate patient safety incidents in healthcare, identify and analyze root causes and contributing factors, and develop recommendations. Participants will learn how to conduct an RCA through interactive exercises and group work. The workshop will cover diagramming to support incident analysis, identification of contributing factors, summarizing findings and developing and implementing recommended actions.
Day 2: Prospective Risk Assessment Using Failure Mode and Effects Analysis (FMEA)
The workshop curriculum is derived from the Canadian Failure Mode and Effects Analysis Framework Version II (2016).
Failure Mode and Effects Analysis (FMEA) is a technique used to identify process and product problems before they occur. This half-day workshop builds on the principles learned in Day 1, with a change in focus to proactive risk assessment and process redesign.
Through interactive group work, participants will learn how to diagram a process, how to identify potential failures, and how to redesign processes with consideration of human factors principles to decrease the likelihood of a failure impacting a patient.
FMEA is a team-based, structured process. It is forward-looking, in contrast to the retrospective approach of incident analysis and techniques such as root cause analysis. FMEA is based on the premise that all systems and processes contain embedded system failures.