Resources & News

Browse our resources to support your work in patient safety.

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Human Factors Matrix

A matrix to help healthcare professionals apply human factors principles during root cause analysis to identify strong strategies to improve patient safety.

Robin Carter (consultant) 10/3/24 Robin Carter (consultant) 10/3/24

OPSC Patient Safety Minute: Building Your RCA Muscles with Success Cause Analysis

Guest User 8/1/24 Guest User 8/1/24

System-Focused Event Investigation and Analysis Guide

System-Focused Event Investigation and Analysis Guide, AHRQ Communication and Optimal Resolution (CANDOR) Toolkit: The "Solutions Meeting" section of this guide (and Appendix F) offer a walk-through on how to run an action planning meeting. It includes brainstorming, evaluating solutions for effectiveness and sustainability, measurement, and a description of the expected outputs.

Oregon Patient Safety Commission 8/4/22 Oregon Patient Safety Commission 8/4/22

VHA National Center for Patient Safety: Root Cause Analysis

Guest User 9/7/21 Guest User 9/7/21

Plan-Do-Study-Act Worksheet

The The Institute for Healthcare Improvement’s Plan-Do-Study-Act (PDSA) Worksheet is a useful tool for documenting a test of change.

Guest User 8/20/21 Guest User 8/20/21

PDSA Cycle Gift Wrapping Activity

This exercise is a fun team building activity that also allows participants to work through the different stages of the Plan-Do-Study-Act (PDSA) cycle.

Oregon Patient Safety Commission 8/9/21 Oregon Patient Safety Commission 8/9/21

Long-Term Care Falls Investigation Guide Toolkit

This toolkit developed by OPSC and community partners offers long-term care providers tools and resources to strengthen their falls investigation process.