Redesigning Event Review with RCA2.

United States Meeting/Conference

Redesigning Event Review with RCA2.

November 5, 2023

Institute for Healthcare Improvement. March 13 - April 23, 2024.

Root cause analysis (RCA) is a widely recognized retrospective strategy for learning from failure that is challenging to implement. This series of webinars will feature an innovative approach to RCA that expands on the concept to facilitate its use in incident investigations. Instructors for the series will include Dr. Terry Fairbanks and Dr. Tejal K. Gandhi.

Conference information

Related Resources From the Same Author(s)

Creating Workforce Joy and Wellbeing.

March 6, 2024 - May 20, 2024

The International Forum on Quality and Safety in Healthcare Europe.

April 10, 2024 - April 12, 2024

Certified Professional in Patient Safety Review Course.

March 7, 2024 - March 8, 2024

Improving Patient Safety with Human Factors Methods.

April 17, 2024 - April 18, 2024

Principles for Improving Patient Safety Measurement Webinar

March 4, 2020

TeamSTEPPS Master Training Course.

January 30, 2024 - February 1, 2024

Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management.

April 4, 2022

IHI Lucian Leape Institute.

December 5, 2007

The IHI Open School.

April 29, 2009

IHI Open School Patient Safety Curriculum

February 22, 2012

Patient Safety Awareness Week.

March 12, 2023 - March 18, 2023

IHI Fellowship Program.

August 30, 2023

Accuracy at every step: the challenge of medication reconciliation.

April 5, 2006

DAISY Award for Extraordinary Nurses in Patient Safety.

September 18, 2023

STate Action on Avoidable Rehospitalizations.

August 3, 2011

National Steering Committee for Patient Safety.

June 27, 2018

COVID-19 Special Series

May 12, 2020

Safe Site Invasive Procedure—Non-Operating Room.

October 6, 2010

‘They are terrified’: fearing coronavirus, people with potentially fatal conditions avoid emergency care.

May 6, 2020

Q: What scares doctors? A: Being the patient.

April 26, 2006

Potentially dangerous confusion between Bloxiverz (neostigmine) injection and Vazculep (phenylephrine) injection.

April 1, 2015

Doctor’s orders killed cancer patient: Dana-Farber admits drug overdose caused death of Globe columnist, damage to second woman.

March 27, 2005

Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary manslaughter.

May 6, 2009

ISMP's second QuarterWatch report shows sharp increase in reports of serious adverse drug events.

November 5, 2008

International Comparisons: A Focus on Quality of Care.

March 26, 2014

Implement strategies to prevent persistent medication errors and hazards.

April 5, 2023

Two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes.

April 12, 2017

A Just Culture Guide.

April 18, 2018

A Conversation on Transparency and Patient Safety.

April 13, 2016

Healthcare Inspection—Emergency Department Patient Deaths: Memphis VAMC, Memphis, Tennessee.

November 13, 2013

Controlled substance drug diversion by healthcare workers as a threat to patient safety.

March 14, 2023

Addressing the Opioid Crisis in the United States.

November 2, 2016

Medication Safety During the COVID-19 Pandemic: What Have We Learned in the United States.

June 23, 2020

Optimizing a Business Case for Safe Health Care: An Integrated Approach to Safety and Finance.

July 12, 2017

Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era.

December 13, 2017

Diagnostic Centers of Excellence (X01 Clinical Trial Not Allowed).

March 22, 2023

5 Million Lives Campaign.

December 13, 2006

Introduction to Trigger Tools for Identifying Adverse Events.

December 6, 2006

What medications does your patient take? Enhancing medication safety in the outpatient setting.

April 4, 2007

Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals NHS Foundation Trust.

April 15, 2020

In men, it's Parkinson's. In women, it's hysteria.

September 4, 2019

Why admitting to mistakes can help doctors (and patients).

October 4, 2023

Is the FDA to blame for drug shortages?

August 8, 2012

Simulation techniques for teaching time-outs: a controlled trial.

June 1, 2016

Medication errors involving healthcare students.

March 30, 2016

Warning! Severe burns and permanent scarring after glacial acetic acid (≥99.5%) mistakenly applied topically.

February 6, 2013

Why do so many Black women die in pregnancy? One reason: doctors don't take them seriously.

May 31, 2023

How to Make Your Hospital Stay Safer and Cheaper: A Checklist.

November 7, 2012

Experts offer smart tips for smart pumps.

August 15, 2007

Integrating patient safety into curriculum.

April 18, 2007

Hospital Preparedness for a COVID-19 Surge: Assessment Tool.

November 25, 2020

Advancing the Safety of Acute Pain Management.

March 27, 2019

Patient Safety Essentials Toolkit.

May 29, 2019

No Place Like Home: Advancing the Safety of Care in the Home.

July 18, 2018

Fixing Healthcare Delivery.

August 13, 2014

How-to Guide: Prevent Obstetrical Adverse Events.

October 24, 2012

A deadly epidural, delivered by a doctor with a history of mistakes.

February 1, 2023

AI can't replace doctors. But it can make them better.

October 31, 2018

At Walgreens, complaints of medication errors go missing.

March 11, 2020

Petty, dangerous, disruptive doctors: watch out!

August 12, 2015

Software for symptoms.

January 31, 2007

The NHS Patient Safety Strategy.

July 24, 2019

Safer Together: A National Action Plan to Advance Patient Safety.

September 16, 2020

Safer Together Survey: Advancing Patient and Workforce Safety

January 18, 2023

Rise to Health Coalition.

December 14, 2022

How-to Guides: Improving Transitions from the Hospital to Reduce Avoidable Rehospitalizations.

August 8, 2012

How-to Guide: Multidisciplinary Rounds.

March 10, 2010

California doctors alarmed as state links their opioid prescriptions to deaths.

February 6, 2019

National Healthcare Quality and Disparities Report Chartbook on Patient Safety.

March 22, 2023

Creating a Communication Coaching Structure and Support for your CRP Program.

September 12, 2022 - September 12, 2022

Driving Learning and Improvement After RCA2 Event Reviews.

January 26, 2023 - January 26, 2023

The Good, The Bad, and The Ugly: Patient Experiences with CRPs.

October 21, 2021 - October 21, 2021

The Power of Medical Malpractice Stories to Improve Patient Safety.

May 19, 2022 - May 19, 2022

Lack of standard dosing methods contributes to IV errors.

September 5, 2007

IV vincristine survey shows safety improvements needed.

March 8, 2006

For patients, a list of hospital hazards.

January 14, 2009

Electronic data collection using MedWatchPlus portal and rational questionnaire.

November 12, 2008

Measurement of diagnostic errors is a key first step to their reduction.

December 9, 2015

What Happened to Patient Safety.

June 14, 2023

July 2011 Author in the Room Teleconference.

January 30, 2005

The Joint Commission and National Quality Forum Announce 2022 Eisenberg Award Recipients.

February 1, 2023

Optimizing patient safety through system strategies and patient engagement.

July 8, 2020

Drug shortages: national survey reveals high level of frustration, low level of safety.

October 6, 2010

Smart pump custom concentrations without hard "low concentration" alerts.

March 14, 2012

A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning.

November 5, 2014

Moving Measurement into Action: Global Principles for Measuring Patient Safety.

January 8, 2020

The Future of NHS Patient Safety Investigation.

April 4, 2018

Providing Safe, High-Quality Maternity Care in Rural US Hospitals. IHI Innovation Report.

March 18, 2020

How a change in hospital policy saved thousands of lives.

November 8, 2017

"Sully" Sullenberger takes on patient safety.

September 5, 2012

FDA recommends health care professionals discuss naloxone with all patients when prescribing opioid pain relievers or medicines to treat opioid use disorder.

August 5, 2020

The hospital ran out of her child's cancer drug. Now she's fighting to end shortages.

November 1, 2023

FDA requiring color changes to Duragesic (fentanyl) pain patches to aid safety―emphasizing that accidental exposure to used patches can cause death.

October 9, 2013

Hospira Carpuject pre-filled cartridges—drug alert: products may contain more than the intended fill volume.

May 30, 2012

Design of endoscopic retrograde cholangiopancreatography (ERCP) duodenoscopes may impede effective cleaning.

March 4, 2015

Doctors were sure they had Covid-19. The reality was worse.

May 5, 2021

Telemedicine: Ensuring Safe, Equitable, Person-Centered Virtual Care.

March 2, 2022

Declaration to Advance Patient Safety.

May 25, 2022

Seven Leadership Leverage Points for Organization-Level Improvement in Health Care. Second edition.

June 1, 2005

Leadership Guide to Patient Safety: Resources and Tools for Establishing and Maintaining Patient Safety.

September 28, 2005

Related Resources

Creating Workforce Joy and Wellbeing.

March 6, 2024 - May 20, 2024

Improving Patient Safety with Human Factors Methods.

April 17, 2024 - April 18, 2024

CUSP Implementation Training.

January 16, 2024 - January 16, 2024

TeamSTEPPS Master Training Course.

January 30, 2024 - February 1, 2024

ISMP Medication Safety Intensive.

November 30, 2023 - December 1, 2023

Annual Communication, Apology, and Resolution (CARe) Forum.

August 10, 2023

Unequal Treatment Revisited: A Workshop Series.

September 26, 2023 - September 27, 2023

TeamSTEPPS Master Training Virtual Course.

September 7, 2023 - November 2, 2023

APSF Stoelting Conference.

September 6, 2023 - September 7, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

World Patient Safety, Science & Technology Summit.

June 1, 2023 - June 2, 2023

Emerging Topics in Quality Improvement.

February 14, 2023 - February 14, 2023

Driving Learning and Improvement After RCA2 Event Reviews.

January 26, 2023 - January 26, 2023

A multicenter collaborative effort to reduce preventable patient harm due to retained surgical items.

November 30, 2022

Healthcare Safety Investigations Conference 2022.

August 3, 2022

A Conversation Among Stakeholders on Medical Malpractice.

April 26, 2022 - April 26, 2022

Patient Safety Primers

Strategies and Approaches for Investigating Patient Safety Events

March 30, 2022

Healthcare Systems Ergonomics and Patient Safety Triennial Conference.

November 2, 2022 - November 4, 2022

Root cause analysis to identify contributing factors for the development of hospital acquired pressure injuries.

July 7, 2021

Preventable morbidity and mortality among non-trauma emergency surgery patients: the role of personal performance and system flaws in adverse events.

May 12, 2021

Implementing a human factors approach to RCA(2) : tools, processes and strategies.

March 10, 2021

TeamSTEPPS for the COVID-19 Crisis.

February 10, 2021

How communication "failed" or "saved the day": counterfactual accounts of medical errors.

February 3, 2021

SOPS Surveys.

December 28, 2020

Making communication and resolution programmes mission critical in healthcare organisations.

November 11, 2020

Patient misidentification events in the Veterans Health Administration: a comprehensive review in the context of high-reliability health care.

October 21, 2020

Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse Events.

July 22, 2020

The Power to Predict: Leveraging Medical Malpractice Data to Reduce Patient Harm and Financial Loss.

June 24, 2020

Medication Safety During the COVID-19 Pandemic: What Have We Learned in the United States.

June 23, 2020

Diagnostic Strategy for the COVID-19 Pandemic – Bench to Bedside to Blueprint for Policymakers.

April 22, 2020

See More About The Topic

Facility and Group Administrators

Risk Managers

Quality and Safety Professionals

Active Errors

Latent Errors