Let's Talk RCA's

Save the Date for our Webinar: Let's Talk RCA's

When: Thursday, November 4th, 2021

Time: 11:00am - 12:30pm (CT) | 12:00pm - 1:30pm (ET) | 9:00am - 10:30am (PT)

Let's Talk RCA's (Root Cause Analyses) -  HF Practitioners will discuss their experience working with RCA's at their institutions, followed by an open discussion about what works, what doesn't, and how we can create better processes.

Presenters:

• Oren Guttman, MD, MBA
• Laura Barg-Walkow, PhD, CHFP
• Valerie Noble, MSc and PhD
• Rebecca Butler, MA

Oren Guttman, MD, MBA, is a practicing Associate Professor of Anesthesiology in the Jefferson Sidney Kimmel College of Medicine. He currently serves as the Enterprise Vice President for High Reliability & Patient Safety for the Jefferson Health System and the Chief Quality and Safety Officer for Abington and Lansdale Hospitals. Additionally, he is the chief architect of Jefferson Health’s Safety Management System. Dr. Guttman will present Jefferson Health’s Serious Safety Event Investigation System, focusing on the comprehensive Root Cause Analysis system that integrates, systems engineering, human factors, and human centered design elements into its methods, processes, and tools.

Laura Barg-Walkow, PhD, CHFP, is a Human Factors Engineer at Children's Hospital Colorado (CHCO). She will share CHCO’s use of human factors in their RCA process for Serious Safety Events (SSEs) and precursor safety events. Laura will address her varying levels of involvement in different cases (e.g., interviews, discussion of sequence of events and root causes) and process improvements. CHCO strives to ensure SSE action items focus on high-quality systems interventions rather than person interventions. Laura will also discuss effective involvement of human factors in the context of limited resources.

Valerie Noble, MSc, PhD, is a Chartered Physiotherapist and Ergonomics Adviser at St Luke’s Hospice Plymouth. She will be presenting her hospital's process of introducing a Type II safety thinking approach to learning events in the hospice environment. Valerie will also discuss how methods employed to research serious vehicle-related incidents have helped develop the learning events process.

Rebecca Butler, MA, is an operations manager and human factors specialist for the system safety program at MedStar Health. She will discuss MedStar Health’s event review process, which applies systems-thinking to accomplish timely, thorough, and just responses to patient safety events. Since development, this approach has been published as the AHRQ CANDOR event review process, and also used to influence the RCA2 tool developed by the Institute for Healthcare Improvement. Rebecca will demonstrate the review process and share examples of events along with the strong actions made possible by using this thorough systems approach.