Department of Veterans Affairs National Center for Patient Safety –Root Cause Analysis

The National Center for Patient Safety uses a multi-disciplinary team approach, known as Root
Cause Analysis – RCA – to study health care-related adverse events and close calls. The goal of
the RCA process is to find out what happened, why it happened, and how to prevent it from
happening again. Because the Center’s Culture of Safety is based on prevention, not punishment,
RCA teams investigate how well patient care systems function. The focus is on the “how” and
the “why,” not on the “who.” Through the application of Human Factors Engineering (HFE)
approaches, the National Center for Patient Safety aims to support human performance.

Decision Tree for Unsafe Acts Culpability

The decision tree for unsafe acts culpability is a tool available for download from the Institute for
Healthcare Improvement Web site. Staff can use this decision tree when analyzing an error or
adverse event in an organization to help identify how human factors and systems issues
contributed to the event. This decision tree is particularly helpful when working toward a
nonpunitive approach in an organization.

AHRQ Patient Safety Education and Training Catalogue

The Agency for Healthcare Research and Quality’s Patient Safety Education and Training
Catalog consists of patient safety programs currently available in the United States. The catalog,
which is featured on AHRQ’s Patient Safety Network, offers an easily navigable database of
patient safety education and training programs consisting of a robust collection of information
each tagged for easy searching and browsing. The new database identifies a number of
characteristics of the programs, including clinical area, program and learning objectives,
evaluation measures, and cost. The clinical areas in the database align with the PSNet


PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

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The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.