PATIENT SAFETY WEBINAR:
A Focused Review of Harmful Events

A Clarity PSO Educational Webinar from August 2, 2017


In today’s healthcare industry, providers are constantly having to balance competing priorities throughout every step of the care delivery process. Healthcare as an industry has a lot to learn from its fellow zero-error/high-reliability-striving industries such as aviation, nuclear power, and chemical processing--all three of which involve high stakes, high stress, complex processes, and multitudes of influencing factors. Yet healthcare’s ultimate output is the “healing” (whether that be curative or palliative) of a human being, with each patient being a unique ecosystem within their own constantly evolving macrosystem. Needless to say, the challenges are astounding!

Tom Piotrowski, RN, MSN, Executive Director of Clarity PSO, leads this webinar examining the challenges, including error types, pathways, and potential rationales, for defects in care delivery. He and his team examined over 82,000 safety events reported in the past five years in order to paint a picture of what errors look like today, and to assess the impact of those errors. This presentation represents the first publishing of their findings.


Featured Speakers:

Tom Piotrowski, RN, MSN, Executive Director, Clarity PSO
Heather DeMoss, RN, BSN, Clinical Operations Manager, Clarity PSO




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