Speaker:
Carla Snyder, MHA, MT(ASCP)SBB Executive Director
Nebraska Coalition for Patient Safety
Description:
Once a safety event or near miss occurs, the real challenge becomes making sense of what happened and deciding what to do next. This part two of the three-part Learning Lab series focuses on how to evaluate event reports, conduct effective reviews, and uncover meaningful insights without bias. Participants will learn how to improve the quality of safety information, make stronger triage decisions, and translate findings into actions that actually reduce risk. The emphasis is on moving beyond surface level fixes to deeper learning that reflects how work truly happens. This session builds on part one and prepares participants to carry insights forward into sustained improvement and communication.
Learning Objectives:
Evaluate patient safety event reports for clarity, consistency, and usefulness to support effective triage, escalation, and review decisions.
Conduct interviews and learning reviews that reduce hindsight bias and focus on understanding how work actually occurred at the time of the event.
Translate investigation findings into meaningful, risk reducing actions rather than weak or one-time fixes.
Explain how the tools discussed (SAC Matrix, Interviewing Tips, Cause Mapping and Causal Statements, Strength of Interventions, etc.) can be used to improve your analysis and response to reported events.
Registration for part three of this Learning Lab series coming soon. If you missed part one of the Learning Lab series, you can access the on-demand version.