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Updated: Dec 29 2021

Medical Error Analysis

  • Snapshot
    • An academic medical center had 15 cases of adenovirus infection amongst patients on the medicine floor over the course of 2 weeks. An investigative committee performs a root cause analysis to determine the cause of this outbreak in hopes to prevent future outbreaks from recurring.
  • Root Cause Analysis (RCA)
    • Definition
      • a problem solving method that focuses on finding the cause (the root) of a medical error in order to
        • identify preventative measures which are
          • subsequently implemented
    • RCA attempts to answer
      • what happened?
      • why did it occur?
      • how can we prevent this from occuring again?
    • This technique is applied after the medical error occurs to prevent it from recurring
  • Failure Mode and Effects Analysis (FMEA)
    • Definition
      • a technique used to evaluate risks in order to identify and eliminate
        • known failures
        • potential failures
        • systemic, design, process, and service issues
    • This technique is applied to prevent medical errors from occuring in the first place
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