Patient Harm Occurred - Now What?

Medical errors are a leading cause of preventable harm in healthcare settings. In this critical CME/CE course, Patient Harm Occurred: What Now, participants explore what to do when a potential medical error has occurred. This course is the second in a series on medical error prevention, providing an in-depth overview of how to approach, analyze, and learn from adverse patient safety events.

Learners are introduced to Root Cause Analysis (RCA), a structured method for investigating the underlying reasons for errors and adverse events. The course outlines the three essential elements of an RCA, explains the tools commonly used in the analysis process, and explores the key reasons why process improvement initiatives often fail to achieve sustainable outcomes.

Fulfilling the mandatory topic requirements for several states, this course addresses Risk Management, Medical Error Prevention, Patient Safety, and Medical Ethics. It is designed for physicians, physician assistants, and nurses across states, including Florida, Connecticut, Pennsylvania, Michigan, Texas, Nevada, Massachusetts, and the District of Columbia.

Educational Objectives

• Verbalize three core elements of a Root Cause Analysis (RCA).
• Differentiate between various tools used in conducting a Root Cause Analysis.
• Recall a common reason why process improvement efforts may fail in healthcare systems.

Who Should Take This Course

This course is recommended for:

• Physicians practicing in Florida, Connecticut, Pennsylvania, New York, Massachusetts, Michigan, Nevada, Texas, and the District of Columbia.
• Physician Assistants in Florida and Nevada.
• Registered Nurses and Advanced Practice Nurses in Florida and Connecticut.
• Healthcare providers involved in patient safety, risk management, quality improvement, and medical ethics.
• Any clinician seeking to understand how to prevent the recurrence of adverse events through structured analysis and systems improvement.

Did You Know?

• Medical errors are estimated to be the third leading cause of death in the United States. [Source: BMJ, 2016]
• Accrediting organizations, such as The Joint Commission, follow a sentinel events mandate that requires Root Cause Analysis (RCA). [The Joint Commission]
• Studies show that up to 70% of process improvement initiatives in healthcare fail due to a lack of leadership engagement and follow-through. [Harvard Business Review, 2020]
• Common RCA tools include fishbone diagrams, Pareto charts, flowcharts, and the '5 Whys' technique.
• Effective RCA not only identifies what went wrong but also uncovers system-level gaps that can prevent future incidents.