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COME Exercise/Event Review This document will be reviewed by the SWIM to evaluate if this exercise/event contains sufficient tasks for a COME Position Task Book (PTB) training opportunity. EXERCISE

How to fill out system-focused event investigation and

How to fill out system-focused event investigation and

1. To fill out a system-focused event investigation, follow these steps:
2. Start by gathering information about the system-focused event, such as the date, time, and location of the incident.
3. Identify the individuals or teams involved in the system-focused event and document their roles and responsibilities.
4. Collect any relevant documentation or evidence related to the event, such as incident reports, logs, or surveillance footage.
5. Analyze the sequence of events leading up to the system-focused event, identifying any contributing factors or root causes.
6. Document any actions taken during or after the event to mitigate its impact and prevent future occurrences.
7. Conduct interviews with individuals involved in the event to gather additional information and insights.
8. Review any existing policies, procedures, or protocols related to the event to identify any gaps or areas for improvement.
9. Summarize your findings and recommendations in a comprehensive report, including any proposed changes or corrective actions.

Who needs system-focused event investigation and?

1. System-focused event investigation is typically needed in organizations or industries where system failures or incidents can have significant consequences.
2. This includes sectors such as healthcare, aviation, industrial manufacturing, and transportation.
3. Anyone responsible for ensuring the safety, reliability, and efficiency of complex systems can benefit from system-focused event investigation.
4. This may include safety managers, quality assurance professionals, risk management teams, or regulatory bodies.

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What is system-focused event investigation?

System-focused event investigation involves examining the underlying system issues that contributed to an event or incident.

Who is required to file system-focused event investigation?

Healthcare facilities and providers are required to file system-focused event investigations.

How to fill out system-focused event investigation?

System-focused event investigations are typically filled out by documenting the contributing factors, root causes, and recommended actions to prevent recurrence.

What is the purpose of system-focused event investigation?

The purpose of system-focused event investigation is to identify and address the systemic issues that lead to patient safety events.

What information must be reported on system-focused event investigation?

Information such as contributing factors, root causes, and recommended actions must be reported on system-focused event investigation.