2007-2008 Session One: Resources

Listed here are the presentations from the September 17-21, 2007 Patient Safety Improvement Corps Conference (TeamSTEPPS presentations were provided on a CD included in the TeamSTEPPS binder). Some other useful presentations are also included at the end of the list.

Module One:  Who We Are, How We Got Here, What We Hope To Accomplish

Marge Keyes gave this broad introduction to the Patient Safety Improvement Corps. Available as a .ppt file

Module Two: Patient Safety – Why Bother?

This is Jim Bagian’s introductory presentation that explains the history and problem of patient safety, lessons learned from aviation, and experience gained by the VA. Available as an .html file.

Module Three: Human Factors Engineering and Patient Safety

Because a major emphasis of the VA method of conducting root cause analysis includes considering the human factors approach to solving problems, this presentation is useful as an introduction to human factors engineering, which is a new topic for many people. Available as a ppt file.

Module Four: RCA Approaches

The objective of this presentation is to briefly address various approaches to doing root cause analysis and comparing their similarities and differences. Available as a .ppt file.

Module Five: Flow Diagramming

One of the early steps of conducting a root cause analysis is the development of a flow diagram. This presentation is useful in showing the RCA team why it’s important to create a flow diagram and how to do it. Available as a .ppt file.

Module Six: Root Cause and Contributing Factors

When they are at the point of writing root cause statements, this presentation is useful in showing RCA team members the importance of creating appropriate root cause statements and how to do it. The Five Rules of Causation (excerpted from David Marx) are outlined.  Available as a .ppt file.

Other useful presentations:

Module Seven: Interviewing Tips

The flow diagram will help the RCA team figure out who needs to be interviewed. This presentation (with the accompanying handout from the course notebook) outlines how to prepare for interviews, techniques to draw out information, and other important things to consider when interviewing.  Available as a .ppt file.

Module Eight: Root Cause Analysis - How to Get Started

This presentation is ideal for your first RCA team meeting. It provides basic information about root cause analysis and the process of conducting a root cause analysis. It emphasizes the reason for doing a root cause analysis - to answer the questions: What happened? Why did it happen? and What are we going to do to prevent it from happening again? See also Module Seventeen. Available as a .ppt file.