She’ve led or contributed to many root cause analyses (RCAs) over the years. Using a methodical approach to deduce the root causes of problems, communication failure was always either a contributing factor or the singular root cause of a medical error.
Types of communication errors she frequently uncovered:
- A busy physician failing to read their Epic inbox messages
- A practice’s failed attempts to connect with a patient regarding pathology results – eventually leading to the notification falling through the cracks, with disastrous results.
Taking a systems approach, under examination is the question, “How can we support physicians and other healthcare team members to reduce medical errors by improving communication?”
source by: SE HEALTHCARE Performance Analytics & Solutions