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IHI Annual Forum 2024

Dedicated improvement professionals from across the globe will be convening to tackle health care's most pressing challenges: improvement capability, patient and workforce safety, equity, climate change, artificial intelligence, and more.

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Andrew Resnick and Steve M.

Innovation Theater: The Root Cause Analysis on Drift: Solving for CLABSI is so 2005!

Andrew Resnick and Steve Mrozowski

Tuesday, December 10, 2024, 5:45 – 6:15pm

Recent literature is citing significant regression in patient safety with some claiming the state-of-safety resembles the levels of unreliability seen in 1999 when To Err is Human was published. When the solutions to our common healthcare quality problems are so well known, why is it so hard to sustain gains?  One cause of the regression in patient safety is at-risk behavior (drift) demonstrated by staff and lost perception of risk. Join Andrew Resnick and Steve Mrozowski as they discuss how anticipating and recognizing drift can prevent an organization from experiencing slow, incremental movement of system operations that can ultimately lead to adverse outcomes. 

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Quality, Safety, and High Reliability
Quality, Safety, and High Reliability

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