Root Cause Analysis of Complex Events in a Hospital: How Ergonomics & Human Factors Can Help

  • Room: Versailles 4
  • Session Number: HE1
Tuesday, November 02, 2021: 2:10 PM - 3:00 PM

Speaker(s)

Speaker
Leah Konwinski
Mgr, Transformation & Human Factors
Spectrum Health

Description

This session will explain the normal root cause analysis (RCA) process in a healthcare setting, and what challenges exists. It will then describe how advanced analysis methods familiar to the Ergonomics and Human Factors discipline can enhance the team’s ability to understand how events occur in complex systems and thus guide more appropriate countermeasure identification. Specifically, it will review the Functional Resonance Analysis Method (FRAM) and the Failure Modes and Effect Analysis (FMEA). It will end with case studies of events to describe the strong outcomes achieved with this approach. 

Track(s)


Learning Objectives

1. Understand the challenges facing healthcare with respect to root cause analysis of safety events
2. Understand the advanced analysis tools such as FMEA and FRAM and how they are better suited to complex systems such as healthcare
3. Understand how and when to apply advanced analysis tools in the healthcare setting