Medication safety:
Incident analysis and prospective risk assessment

Thursday, March 2 and Friday, March 3, 2017
1.5 day workshop

Registration is closed

This 1.5 day workshop provides healthcare practitioners with background theory and hands-on practice in incident analysis (root cause analysis, RCA) and proactive risk assessment using failure mode and effects analysis (FMEA)

Day 1:
Incident Analysis - Root Cause Analysis (RCA)

The Root Causes Analysis (RCA) portion of this workshop has been assigned 6.5 CEUs by the Ontario College of Pharmacists. The workshop curriculum is derived from the Canadian Incident Analysis Framework.

Program Abstract:

The program begins with an overview of the system approach in the management of error and introduction to human factors engineering principles. RCA is a tool to help investigate patient safety incidents in healthcare, identify and analyze root causes and contributing factors, and develop recommendations. Participants will learn how to conduct an RCA through interactive exercises and group work. The workshop will cover diagramming to support incident analysis, identification of contributing factors, summarizing findings and developing and implementing recommended actions.

Day 2:
Prospective Risk Assessment Using Failure Mode and Effects Analysis (FMEA)

The workshop curriculum is derived from the Canadian Failure Mode and Effects Analysis Framework Version II (2016).

Program Abstract:

Failure Mode and Effects Analysis (FMEA) is a technique used to identify process and product problems before they occur. This half-day workshop builds on the principles learned in Day 1, with a change in focus to prospective risk assessment and process redesign.

Through interactive group work, participants will learn how to diagram a process, how to identify potential failures, and how to redesign processes with consideration of human factors principles to decrease the likelihood of a failure impacting a patient.

FMEA is a team-based, structured process. It is forward-looking, in contrast to the retrospective approach of incident analysis and techniques such as root cause analysis. FMEA is based on the premise that all systems and processes contain embedded system failures.

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Medication safety:
Incident analysis and prospective risk assessment

Thursday, March 2 and Friday, March 3, 2017
1.5 day workshop

Registration is closed

This 1.5 day workshop provides healthcare practitioners with background theory and hands-on practice in incident analysis (root cause analysis, RCA) and prospective risk assessment using failure mode and effects analysis (FMEA)

Day 1:
Incident Analysis - Root Cause Analysis (RCA)

Learning Objectives for RCA:

On completion of the RCA portion of the workshop, participants will be able to:

1. Describe the impact of system factors on error potential;
2. Apply basic human factors engineering principles in a health care environments;
3. Describe the importance of each component of the incident management continuum;
4. Complete a system-based analysis using a constellation diagram;
5. Develop redesign strategies based on systems theory and basic human factors principles; and
6. Apply principles learned to support medication safety activities in their practice setting.

Day 2:
Prospective Risk Assessment Using Failure Mode and Effects Analysis (FMEA)

Learning Objectives for FMEA:

On completion of the FMEA portion of the workshop, participants will be able to:

1. Identify processes suitable for analysis using FMEA;
2. Describe the steps required to complete an FMEA;
3. Map out a process and identify potential failure modes;
4. Develop redesign strategies based on systems theory and basic human factors principles; and
5. Apply principles learned to support medication safety activities in their practice setting.

For more information regarding RCA and FMEA, please visit: www.ismp-canada.org/rca.htm and www.ismp-canada.org/fmea.htm

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