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Diagnosis Error, Part 4: Learning from Cases - Root Cause Analysis (1 credit, Monograph)

Hours: 1.00

Best suited for: Physicians of all specialties, residents, clinicians, and other healthcare providers engaged in patient care.

Target Audience: Physicians of all specialties, residents, and clinicians engaged in diagnosis. Other interested healthcare practitioners are also welcome to participate.

Original Release Date: April 23, 2015
Review Date:
Expiration Date: April 23, 2018

Description: Aviation safety has improved by learning from disasters and near misses. Diagnostic error may benefit from the same approach, but new tools are needed. These include facilitating reports from involved patients and providers; leveraging electronic data; and Root Cause Analysis to examine all of the cognitive, system-related and other causes. The purpose of RCA is to enable changes that help prevent subsequent similar errors. This is Module 4 in a 6 part series by Mark Graber, each designed to stand alone, but participants are encouraged to complete the series.

Learning Objectives: Upon completion, participants should be able to

1)    Describe 4 methods for identifying diagnostic errors.  
2)    Explain 4 main categories of causes of diagnostic error on the fishbone diagram.
3)    Conduct a Root Cause Analysis of a diagnostic error or a pattern of diagnostic errors.
4)    Identify solutions and implement a change process to reduce the future likelihood of the
       identified error.

Learning Assessment: There will be a post test for this activity with a minimum performance requirement of 4 out of 5 correct answers.

Estimated time to complete activity: 1 hour

Method and Medium: To obtain CME credit, view the entire online presentation, complete the evaluation and post test and print your certificate online.

CME Credit: 1.0


MOC Approved: Through the American Board of Medical Specialties ("ABMS") and Association of American Colleges' ("AAMC") joint initiative to create a wide array of Maintenance of Certification ("MOC") Activities, 'Diagnosis Error, Part 4: Learning from Cases -  Root Cause Analysis ' has met the MOC requirements as a Part II activity by the following ABMS Member Boards:

  • American Board of Allergy and Immunology
  • American Board of Family Medicine
  • American Board of Ophthalmology
  • American Board of Physical Medicine and Rehabilitation
  • American Board of Radiology
  • American Board of Thoracic Surgery
  • American Board of Urology



Residents will earn a certificate of completion. Physicians will earn CME credit. 

CME Information - Read

State Requirements: Based on information from state licensing authorities published by the AMA, this program meets specific CME requirements for the following states:
Florida -  This activity includes content in Preventing Medical Errors
Connecticut - This activity includes content in Risk Management
Massachusetts - This activity includes content in Risk Management
Pennsylvania - This activity includes content in Risk Management / Patient Safety
Texas - This activity includes content in Ethics and/or Professional Responsibility

Disclosure Policy - Read

About the Author: Mark L. Graber, MD, FACP - Read Bio

Disclosure Statement: The author discloses he is an unpaid officer of the Society to Improve Diagnosis In Medicine, has received research grants from the AHRQ and NPSF, and payment from the Australian Clinical Excellence Commission and Best Doctors for developing education curricula. The editors and planning committee members for this activity have no relevant financial relationships to disclose.

Managing Editor: Dawer Azizi, MHA, CPHRM, LAMMICO Director of Risk Management

Editor: Sharon Cusanza, MSN, RN, NEA-BC, LAMMICO Risk Management Education Specialist

Content Advisors/Planning Committee Members - Read

Electronic Hardware and Software Requirements Read

Web Master Contact Information: For assistance, contact Shea Ivey at 866/398-1038 or help@medicalinteractive.com

Disclaimer: This activity is presented as risk management education. It is not legal advice, nor does it establish medical standards of care. Standards of care vary depending on the unique presentation of each patient. The information contained herein is not a substitute for the reasonable discretion of skilled and informed clinicians at the point of care.

Copyright Information: Copyright © 2015

Bibliography: To view and download a Bibliography for this presentation, please select the References button below.

Member and Subscriber Access
Interested in a CME program like this for your team or facility? Contact us to schedule it and talk about pricing.

This course is offered through Experix, a wholly owned subsidiary of Physicians Insurance, and is based on more than 30 years' experience in providing continuing medical education. This course is complimentary for Physicians Insurance members.

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