Mistakes Happen: Improving Patient Care


Despite the increased focus and some evidence of improved outcomes in the 20 years after the release of the IOM report, medical errors continue to be a serious problem. It is imperative that residents, faculty, and staff engage with the clinical site’s efforts to address patient safety.

Participants will recognize that mistakes happen and that is the system (processes) and not the caregivers, the main cause of these mistakes.

At the end of this presentation, participants will learn the criteria and basic epidemiology of medical errors and adverse events. In addition, they will learn how to file an Incident Report reducing the probability that mistakes happen again. Residents and participants will understand the Root Cause Analysis (RCA) process to avoid mistakes. Finally, it is expected that at the end of this session residents feel comfortable participating in a patient safety investigation using the RCA process.