Incident Analysis Learning Program - Module FiveConcise Analysis MethodJanuary 31, 2013
WelcomeTina Cullimore   Sandi Kossey   Erin Pollock   Nadine Glenn   Ioana Popescu
Learning ProgramWhat was learned?What can be done?  How and why? What happened?  Multi-incident     Concise Comprehensive
Learning Objectives• The similarities and differences between a comprehensive  and concise individual incident analysis• T...
Agenda3-parts   • Knowledge expert + Q&A   • Practice leader + Q&A   • Facilitated discussion or Q&A
Introducing: WebEx       Be prepared to use:        - Raise Hand & Checkmark            - Chat & Q&A            - Pointer ...
About You0   Experience with [any] CONCISE analysis   10
PresentationCarolyn Hoffman
Background and Features Need for a “concise” method    •     Informal (mini-RCA)  Formal (NPSA, M&M)       Consistent w...
Concise and Comprehensive                          Action                              Concise        ComprehensiveInclude...
Page 46CanadianIncidentAnalysisFramework
Case: Medication IncidentSetting:  Community hospital & busy home care servicesCurrent process:    hospital faxes referra...
WHAT HAPPENED?
Case: What HappenedBased on the   •   incident report   •   a review of the home care record   •   hospital chart   •   re...
Case: TimelineExample(p.113)
HOW AND WHY IT HAPPENED?
Analyze Information•   Use guiding questions to briefly explore all    categories (Appendix G, Page 89)      •   Use some ...
Case: How and Why
Case: FindingsWork environment   • The lack of a standardized home care risk assessment tool or protocol      increased th...
WHAT CAN BE DONE…?WHAT CAN BE DONE TO REDUCE THE RISK OF  RECURRENCE AND MAKE CARE SAFER
Case: Recommended Actions
Case: Follow-through
WHAT WAS LEARNED?The ultimate objective of analysisFeedback  •   To the organization: patient family, those involved in   ...
Questions?
Real-life ExperienceGordon Luy
Safety at Home: A Pan-Canadian Home CareSafety Study, Root Cause Analysis Sub-Project      - Project #4 – Falls by Home Ca...
Safety At Home StudyLed by Dr. G. Ross Baker of the Institute of Health Policy, Management and Evaluation, at the Univers...
Winnipeg Regional Health AuthorityQuality & Patient Safety Unit   Part of the Research and Applied Learning    Division o...
WRHA Quality Improvement & Patient Safety Unit•   Under the Chief QIPS Officer•   Composed of 3 teams each under a regiona...
WRHA Patient Safety ConsultantA Patient Safety Consultant (PSC) works in collaboration withhealthcare sites/settings/progr...
Safety At Home:Sub-Project #4 – Falls by Home Care Clients  Five specific Home Care cases were selected   from the Manito...
CPSI Concise Analysis MethodologyI. Understand WHAT HAPPENED:     i.         Information gathering (medical records; inter...
I. Understand WHAT HAPPENED: 1.   We reviewed the client’s medical record: (assessments; client      characteristics (e.g....
Incident Analysis – Systems TheoryA system is described as the coming togetherof parts, interconnections and purpose.*Huma...
II. Incident Analysis• Task (care/work process)• Equipment• Work environment• Patient (client) characteristics• Caregiver•...
Constellation Map of Contributing Factors
Case Example• Equipment: Motorized wheelchair; manual wheelchair;  hospital bed; transfer poles in bedroom and bathroom; b...
Factors of Influence in EventEquipment: Motorized wheelchair: client sits too far forward and does not usethe seatbelt.   ...
Summary Statements/Findings• The  client is more at risk for a fall when using the motorized  wheelchair, than the manual ...
Report Format •   Date of Event •   Date Event was discovered •   Brief Description of event •   Date Event Analysis proce...
Reflection• CPSI Concise Methodology  – Very similar to the what we have been using in the    region to review some Critic...
Questions?
Learn from Each Other
Options1. Learn from each other  •   Suggested topics      o   Do you use concise now? For what cases?      o   Is it help...
Breakout SessionSome participants will     Some participants will  stay in the main           “move” to breakout  room    ...
Large Group De-BriefingHighlights from small group discussionNuggets from the Q&A
Recap and Next StepsEnd of session evaluation; Follow up survey• Follow-through and share  what was learned  March 28, 201...
ResourcesLearning Program – previous modules:  http://www.patientsafetyinstitute.ca/English/news/Inci  dentAnalysisLearnin...
Mulţumesc  Thank You
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Module 5 - Concise Analysis Method

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The background, key features and main steps of the concise analysis method are described, discussed and applied in this module together with the main tools used during a concise analysis (timeline, guiding questions, constellation diagram, and statements of findings).

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  • Good morning/ afternoon Welcome back those who were part of the our previous modules Welcome those who just came on board
  • I am Ioana P., PM with CPSI responsible with the management of the framework revisions, design and delivery of the education program and other resources to support you analyze incidents more effectively in order to make care safer. I will be your moderator today.The wonderful people that you see on the screen are contributors to today’s session and you will meet them later in the program
  • Previously on the learning program AND the scope of today’s call Assume that the previous steps in the incident management continuum have been executedConcise method is NEW additionWHAT HAPPENED; HOW AND WHY IT HAPPENED; WHAT CAN BE DONE TO REDUCE THE RISK OF RECURRENCE AND MAKE CARE SAFER; WHAT WAS LEARNED
  • Ioana: due to the increase in the number of participants and their learning needs (the registration form has a few questions about the level of experience and learning objectives)…. And the feedback received following module 1-3 … and iN AN EFFORT TO GIVE EVERYONE AT LEAST ONE NUGGET OF LEARNINGWe changed the original performance elements and decided to offer a deep dive
  • Lines will be muted. Enter questions in the chat box or put your hand up during Q&A and you will be able to ask your question live. The first 2 parts of the meeting are recorded but not the facilitated discussion
  • 1. Raise hand: have you participated in previous modules 2. In chat: what is your learning objective for today? 3. Pointer: next slide
  • Profile experienced participants as experts and encourage them to share their wisdom in the chat box or breakout room. In the evaluations we heard that real life stories are very valuable to you and we should continue to include them. Try to pick names?
  • Carolyn is the Vice President, Clinical Performance Improvement for Alberta Health Services, the largest healthcare delivery organization in Canada. In this role, Carolyn leads a variety of teams including Patient Safety, Clinical Quality, Design & Delivery, and Capacity Building. She is also Senior Advisor to the World Health Organization’s High 5s Initiative with responsibilities that include chairing the Event Analysis Subcommittee. Carolyn is one of the authors of the CIAF and a faculty member for the learning program.  Carolyn`s relationship with CPSI is as long as CPSI`s existence. I had the pleasure to learn from and work with her since 2009 and I must say that no matter what the project or task both the journey and reaching the destination was a true joy. I am confident that you will enjoy the concise analysis learning journey Carolyn will take us through in the next 20 minutes. She is expecting some very good questions from you, so make sure you type them in the chat box or write them down so she can answer them in the Q&A following her presentation. Ladies and gentlemen, our concise analysis knowledge expert Carolyn Hoffman!
  • Comprehensive: permanent harm or death occurred (or risk thereof), incident is complicated or complex, area impacted is micro, meso or macro; contextual pressures are high Concise: incidents or concerns that resulted in no or low harm; may focus on a new incident for which a comprehensive analysis was conductedCarolyn, can you provide an example here?
  • Note that this is an iterative process – not a straight step 1, then 2, etc.May be an opportunity here to engage the participants such as asking them where they USUALLY do to gather information and understand what happened?
  • After gathering all the information, those gaps can start to be filled.Provide in the form of a narrative chronological description.The Detailed Timeline is a collation of information from various sources.This is your starting point for identifying system based factors underlying the incident.You may have IA team members who were not directly related to the event…in fact, consider involving such individuals as appropriate. Often, these “outside eyes” can ask different questions, or identify other factors for team consideration—improves credibility of the review while fostering and nurturing the just and trusting culture.
  • The guiding questions are meant to facilitate a thorough and complete picture of informationThe intent is to leave no information behindBased upon and adapted from international experts in incident analysisFocus on the person is like plucking Kleenex from the box. If you just pull the person and do nothing else…there will be another person coming behind who can potentially experience the same event because we have done nothing to address the system of contributing factors.
  • We don’t expect participants to read. Refer to pg. 115The facilitator created a constellation diagram to visualize and better understand the factors that contributed to the incident and their interconnections.The factors were confirmed by consultation with those engaged in the incident and operational and/or medical leaders. This step was very helpful in summarizing the findings and developing recommended actions.
  • The ultimate goal of incident analysis is to take action to reduce the risk of recurrence and make care saferWhether you are a member of the analysis team, or you are facilitating the analysis process, maintain focus by reminding yourself that if we do nothing, the dark persists, if we use facts as our illumination (not judgement, not punishment, not discipline), we are better able to determine exactly where we can focus attention and effort to make care saferAn upcoming learning module focuses entirely on developing and managing recommended actions. Refer to Section 3.6.6 in the CIAF (Canadian Incident Analysis Framework) document
  • • W1: Establish a standardized home care risk assessment tool for screening patients that are transitioning back to the community from hospital. Consider the feasibility and effectiveness of the regularly assigned home care nurse beginning the screening process with a call from the acute care nurse planning for the patient discharge then completing the assessment with a telephone or in-person client assessment.• CO 1: Develop, implement and evaluate a system-wide Discharge Medication Reconciliation Process. Consider using a pilot test approach initially to determine a successful strategy for spread.
  • Follow-throughAn evaluation was completed by the QI Director one year after the incident analysiswas completed:
  • Raise your hand, your line will be unmuted
  • Gordon is a Patient Safety Consultant with the Quality Improvement and Patient Safety Unit of the Winnipeg Regional Health Authority.  His background is in Social Work with a graduate degree in Social Policy and Administration and his work experience includes Children’s Mental Health and Child Welfare.  He has been leading Critical Incident Reviews for about 3 ½ years.  We heard about the great work Gordon and his team are doing only 2 months ago. In November, Sandi and me met one of Gordon’s colleagues at a learning event organized by our colleagues from the HQCA. Shirley she told us about the great work the Winnipeg team is doing with Concise analysis. Excited to find a great organization to profile and put in the spotlight for the rest of the country we begin to learn more about the team, had a few calls and email exchanges with Gordon and felt very confident that the experience of this team will be valuable to all of you. As you listen to this very practical application of the concise method Carolyn introduced please make sure you capture your questions and comments in the chat box or on paper. Gordon will answer your questions following his presentation. Please join me in welcoming Gordon to our session. Gordon Luy, BSW, MSW WRHA Patient Safety Consultant364-99 Cornish AvenueWinnipeg, MB R3C 1A2Telephone: 204-788-8361Fax: 204-788-8430
  • Raise your hand, your line will be unmuted
  • Facilitated small group discussion20 minute breakout session. Ioana: recognize different levels of experience. Our goal is that each person leave having learned something - if you are new share your questions and challenges- If you are experienced share your solutions If chat box is “hot” say no to breakout Facilitation tips:Begin with a roundtable: name, organization and what you’d like to take home at the end of the sessionAsk to use the pointer to share their level of experiencePick on people to break the ice – point to what was presented earlier and use the one pager for comprehensive as guideCareful not to overwhelm them – ask, listen then talkMake sure they have the feeling that they accomplished something.Additional facilitation questions:What does one need to do to make this completely fail What is the role of patient/ family in the analysis process Describe the steps to create a timeline of the eventPerform the main steps to analyze information to identify contributing factors and relationships
  • Most participants will “move” to breakout roomsSome participants will stay in the main roomThose prompted: click YES to bothpop-up screens to “move”If chat box is “hot” say no to brekout
  • NadineFacilitators report back on process
  • Quick review of what was discussed during the call: Carolyn – background, features and comparision with comprehensive, overview of the steps in concise as presented in CIAF Gordon – practical application of the steps in CIAF concise in both a research study and regular work processesLearn from each other’s experience tips, stories, examples, scenarios Participants will be sent a link for an evaluation of the session immediately following. Please complete in 1 week while fresh in mind. You will need to complete in order to receive your certificate of completion for the module.We will also send you a survey in 6 months to let us know how you are doing and how you have used the principles and learning from the Framework and Learning Program to improve your practice with incident analysis and management.Of course, we invite your feedback, questions or suggestions at any time as to how we might improve the learning program
  • NadineDuring our discussion today, we have referenced a number of resources which can provide you with additional information. Links for these references are provided above.We hope that you will join us for subsequent learning modules.Thank you so much for the opportunity to speak with you today.
  • Module 5 - Concise Analysis Method

    1. 1. Incident Analysis Learning Program - Module FiveConcise Analysis MethodJanuary 31, 2013
    2. 2. WelcomeTina Cullimore Sandi Kossey Erin Pollock Nadine Glenn Ioana Popescu
    3. 3. Learning ProgramWhat was learned?What can be done? How and why? What happened? Multi-incident Concise Comprehensive
    4. 4. Learning Objectives• The similarities and differences between a comprehensive and concise individual incident analysis• The main steps in conducting a concise analysis• Give examples or scenarios of incidents where concise analysis is recommended
    5. 5. Agenda3-parts • Knowledge expert + Q&A • Practice leader + Q&A • Facilitated discussion or Q&A
    6. 6. Introducing: WebEx Be prepared to use: - Raise Hand & Checkmark - Chat & Q&A - Pointer & Text 614-Mar-13 6
    7. 7. About You0 Experience with [any] CONCISE analysis 10
    8. 8. PresentationCarolyn Hoffman
    9. 9. Background and Features Need for a “concise” method • Informal (mini-RCA)  Formal (NPSA, M&M) Consistent with the principles and methodology of analysis Conscious and deliberate decision to focus on the: • Agreed-upon facts • Key contributing factors and findings • Actions for improvement (if any) • Evaluation
    10. 10. Concise and Comprehensive Action Concise ComprehensiveInclude person(s) with knowledge of IA, HF, solutionsdevelopmentFacilitated by an individual with input from patient,local staff & physiciansConducted by an inter-disciplinary medium to large adhoc group (includes also external experts / consultants)facilitated by a knowledgeable individual. Short LongerTime taken for analysis (hours-days) (45-90 days)Identifies contributing factors as well as remedialaction(s) taken (if any) and recommendations forimprovement Reflects intent Incorporates allPrinciples of Incident Analysis principlesEvaluation Component
    11. 11. Page 46CanadianIncidentAnalysisFramework
    12. 12. Case: Medication IncidentSetting: Community hospital & busy home care servicesCurrent process:  hospital faxes referrals to fax line  if 9-5, M-F, home care coordinator reviews faxes & accesses the home care central record  schedule home care visits  if outside business hours home care nursing staff periodically check faxes  sorts by ongoing and new clients  referrals for ongoing given to responsible nurse  pharmacist dispense meds from drug stores in the community.  some attending physicians at comm. hosp fax prescriptions to patients’ drug store for ease of pickupIncident Client (discharged from hospital with meds) found in bathroom. Moderate amount of bright red blood. Transfer to ED.
    13. 13. WHAT HAPPENED?
    14. 14. Case: What HappenedBased on the • incident report • a review of the home care record • hospital chart • referral form…the facilitator responsible to conduct this concise analysisstarted to draft a timeline of the incident.Timeline confirmed and expanded by • Interviews with the client, pharmacist and RNs, • Examination of the drugs involved in the incident
    15. 15. Case: TimelineExample(p.113)
    16. 16. HOW AND WHY IT HAPPENED?
    17. 17. Analyze Information• Use guiding questions to briefly explore all categories (Appendix G, Page 89) • Use some questions or develop incident specific questions to informally discuss the incident with those involved and external experts• Ask • What was this influenced by? • What else affected the circumstances?• Use constellation diagram • Systemic approach • Visual representation • Linkages• Summarize findings
    18. 18. Case: How and Why
    19. 19. Case: FindingsWork environment • The lack of a standardized home care risk assessment tool or protocol increased the likelihood that clients discharged from hospital back to the community would not be accurately triaged to ensure appropriate and timely home care services are provided.Patient • The deterioration in the client’s physical and cognitive abilities increased the likelihood of a medication error in his self medication management.Care team and organization • The lack of a formalized, system-wide and communicated Discharge Medication Reconciliation process (including an updated Best Possible Medication History) decreased the likelihood that the client would receive the appropriate and timely support required for safe medication management.
    20. 20. WHAT CAN BE DONE…?WHAT CAN BE DONE TO REDUCE THE RISK OF RECURRENCE AND MAKE CARE SAFER
    21. 21. Case: Recommended Actions
    22. 22. Case: Follow-through
    23. 23. WHAT WAS LEARNED?The ultimate objective of analysisFeedback • To the organization: patient family, those involved in the incident, the analysis team, etcFeed-forward • Externally to prevent similar incidents from occurring in other organizations, systems, countries • Informing the public and/or media
    24. 24. Questions?
    25. 25. Real-life ExperienceGordon Luy
    26. 26. Safety at Home: A Pan-Canadian Home CareSafety Study, Root Cause Analysis Sub-Project - Project #4 – Falls by Home Care Clients(Canadian Patient Safety Institute)Gordon Luy, BSW, MSWPatient Safety ConsultantWinnipeg Regional Health AuthorityQuality Improvement & Patient Safety Unit
    27. 27. Safety At Home StudyLed by Dr. G. Ross Baker of the Institute of Health Policy, Management and Evaluation, at the University of Toronto.A qualitative study to investigate the root causes and contributing factors that lead to {Falls-; Medication-} related adverse events suffered by patients in home care, and help to form recommendations to prevent similar events in the future.The study was conducted at three provincial sites:Alberta Health Services - Edmonton Zone Home Living Portfolio.Winnipeg Regional Health AuthorityCommunity Care Access Centres (CCAC) of the Greater Toronto Area (GTA)
    28. 28. Winnipeg Regional Health AuthorityQuality & Patient Safety Unit Part of the Research and Applied Learning Division of the WRHA 3 Units in division  Health Information Services  Research and Evaluation  Quality Improvement & Patient Safety
    29. 29. WRHA Quality Improvement & Patient Safety Unit• Under the Chief QIPS Officer• Composed of 3 teams each under a regional Director: o Clinical Office of Patient Safety: 2 Analysts; and, 1 Auditor o Quality Improvement Team: 7 Quality Managers; 2 Coordinators; and, 3 Analysts o Patient Safety Team: 8 Patient Safety Consultants; 1 Patient Safety Pharmacist; and, 1 Education Consultant
    30. 30. WRHA Patient Safety ConsultantA Patient Safety Consultant (PSC) works in collaboration withhealthcare sites/settings/program leaders and other members ofthe Quality and Patient Safety Unit to facilitate the development,implementation and maintenance of the quality and patient safetystrategy.Through system safety reviews (Critical Incident Reviews),PSCs assist staff and physicians throughout the Region to gain anunderstanding of the complex systems in which people work forpotential healthcare system improvements.** The Regional Health Authorities Amendment And Manitoba Evidence Amendment Act (2005)
    31. 31. Safety At Home:Sub-Project #4 – Falls by Home Care Clients  Five specific Home Care cases were selected from the Manitoba site (WRHA) for a detailed review using the CPSI Concise Methodology.  The review included interviewing caregivers, managers, clients and their families regarding events related to a fall which occurred during the period of time that the client was receiving Home Care.
    32. 32. CPSI Concise Analysis MethodologyI. Understand WHAT HAPPENED: i. Information gathering (medical records; interviewing clients, case coordinators and direct service providers (nurses, health care aides) ii. Construct a a brief timeline.II. Analyze information to identify contributing factors and the relationships among them: i. Systems theory and human factors ii. Describe the incident and outcome iii. Identify and define relationships between potential contributing factors iv. Formulate findingsIII. (Develop and manage Recommended Actions) The final report contains the facts, contributing factors, a brief context analysis, and where applicable, recommended actions and a plan for evaluation and dissemination.
    33. 33. I. Understand WHAT HAPPENED: 1. We reviewed the client’s medical record: (assessments; client characteristics (e.g. co-morbidities), medications and changes; equipment; professional consultation; process(es) of care delivery (e.g. history, frequency and purpose of visits); circumstances of fall; etc. 2. We interviewed: - Clients (and family): (recollection of event, factors (e.g. environment – photos taken), services) - Case coordinators: (organization, policies, care plan; roles, workload, resources, training, communication, etc.) - Direct service providers (nurses, health care aides): (roles, workload, scheduling, resources, etc.) 3. We constructed a brief timeline (chronology) of event
    34. 34. Incident Analysis – Systems TheoryA system is described as the coming togetherof parts, interconnections and purpose.*Human Factors: how humans interact with the worldaround them. Human error is viewed as a symptom ofbroader issues within what may be a poorly designedsystem, such as an adverse physical or organizationalenvironment.** * Institute of Medicine. Crossing the Quality Chasm: A new health system for the 21st century. Washington, DC: The National Academy Press; 2001. ** Dekker S. The Field Guide to Human Error Investigations. Aldershot, UK: Ashgate Publishing; 2002.
    35. 35. II. Incident Analysis• Task (care/work process)• Equipment• Work environment• Patient (client) characteristics• Caregiver• Care team (direct service providers and support team)• Organization (policies, culture, capacity-resources)
    36. 36. Constellation Map of Contributing Factors
    37. 37. Case Example• Equipment: Motorized wheelchair; manual wheelchair; hospital bed; transfer poles in bedroom and bathroom; bath seat; Hoyer Lift and slings; Life line.• Work environment: Customized private bungalow; guide dog; client alone at times.• Patient characteristics: Parkinson’s Disease; chronic back pain and hip pain; physically compromised; alert & oriented but at times has impaired judgment and memory issues; quiet and slurred speech; functional hearing; wears glasses.
    38. 38. Factors of Influence in EventEquipment: Motorized wheelchair: client sits too far forward and does not usethe seatbelt. Client: Lack of leg strength to push selfEnvironment: The client and family back in the seat of the motorized prefer that the client lives in the wheelchair. Seating position increases the residence as long as possible. While risk for a fall. Motorized wheelchair is cared for by extended family and preferred for mobility over the manual through Home Care much of the day, wheelchair even though the seating there are periods of time when the position is safer in the manual wheelchair. client is alone. Due to compromised Risk for a fall is increased if the client falls judgment and toileting issues, the asleep in the wheelchair - tendency to fall client may attempt to transfer when asleep is exacerbated by medications. assistance not available which has Also, the client at times attempts to reach led to falls in the past and increases or ambulate without assistance present. the risk for a fall.
    39. 39. Summary Statements/Findings• The client is more at risk for a fall when using the motorized wheelchair, than the manual wheelchair, due to the seating position in the motorized wheelchair and consequent inability to use the seat belt.• Preference for using the motorized wheelchair at home predisposes the client to this risk especially if the client falls asleep while in the wheelchair or forgets that he/she in the wheelchair.• The tendency to fall asleep is exacerbated by medications prescribed to address medical conditions.• The Home Care services provided were maximized according to the funding formula.
    40. 40. Report Format • Date of Event • Date Event was discovered • Brief Description of event • Date Event Analysis process was initiated • Date Event Analysis process was completed • Describe what Home Care Services received prior to the fall. • Describe what Home Care Services received after the fall • Describe the Client’s primary and secondary medical conditions. • Does the Client live alone? • The extent of harm as assessed 24 hours post event. • Outcome of event • Additional Issues • Medications and how related to event • Chronology • Constellation Map • Identification of factors that contributed to the occurrence of this event • Summary Statement
    41. 41. Reflection• CPSI Concise Methodology – Very similar to the what we have been using in the region to review some Critical Incidents (falls and pressure ulcers). – Is a useful framework for the review of an adverse event of limited harm to the patient (client): • Conceptualizing; • Planning; • Conducting; and • Documenting.
    42. 42. Questions?
    43. 43. Learn from Each Other
    44. 44. Options1. Learn from each other • Suggested topics o Do you use concise now? For what cases? o Is it helpful? How long it takes? How is it done? o How did you get started? How did you spread it?2. Q&A with the 2 presenters
    45. 45. Breakout SessionSome participants will Some participants will stay in the main “move” to breakout room rooms- No phone next to your name- Say no when invited to breakout
    46. 46. Large Group De-BriefingHighlights from small group discussionNuggets from the Q&A
    47. 47. Recap and Next StepsEnd of session evaluation; Follow up survey• Follow-through and share what was learned March 28, 2013• Recommendations management March 7, 2013• Multi-incident analysis February 21, 2013
    48. 48. ResourcesLearning Program – previous modules: http://www.patientsafetyinstitute.ca/English/news/Inci dentAnalysisLearningProgram/Pages/Session- Recordings-and-Documents.aspxNational Health System – UK • Three Levels of RCA Investigation – Guidance • Example concise RCA investigation reportsIncident Analysis Tools http://www.patientsafetyinstitute.ca/English/toolsReso urces/IncidentAnalysis/Pages/Tools.aspx
    49. 49. Mulţumesc Thank You

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