Patient Safety Workshop

Learning from Error

June 2010
More details
  • Publisher
    World Health Organization
  • Published
    4th June 2010
  • ISBN 9789241599023
  • Language English
  • Pages 22 pp.
  • Size 8.5" x 11.75"
  • Images bw tables

This booklet which includes a CD-ROM should enable any health-care worker to facilitate a workshop on patient safety. This workshop explores how multiple weaknesses present within the hospital system can lead to error. It aims to provide all health-care workers and managers with an insight into the underlying causes of such events. Although the workshop materials revolve around an error involving the inappropriate administration of vincristine, the underlying principles of why an error occurs are universal and the learning objectives can be applied in any error-related situation.

1) Guidance for Course Organizers
2) Suggested Schedule
3) Factors Contributing to Error
4) Session One: Root Cause Analysis
5) Acknowledgements
Copy Sheet One: Fishbone Template
Copy Sheet Two: Questions to Consider
Copy Sheet Three: Evaluation Form

World Health Organization

World Health Organization is a Specialized Agency of the United Nations, charged to act as the world's directing and coordinating authority on questions of human health. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries, and monitoring and assessing health trends.