Understanding and Preventing Human Error Part I Overview

This module will be discussing the consequences of medical errors, and you will learn from Sorrel King's loss of her daughter, Josie, and from my personal experience that preventable injuries not only cause death but also can lead to permanent life changing injuries. Sitting around and doing nothing is not an option. However we all need to understand and use three key tools to determine the causes of medical errors and to fix them, Root cause analysis, Driver Diagrams, and PDSA cycles. Finally we will discuss the issue of small errors and our tendency to ignore and workaround them. Unfortunately this approach to small problems is one of leading causes for the continued high rate of preventable injuries and deaths in our hospitals and clinics. It is time to fix the little things.

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