Expert training for healthcare, with emphasis on the diagnostic laboratory.
This lesson covers the Causal Tree. By creating the tree, teams are able to link factors and conditions to actions that lead to an undesired event. Using this knowledge, teams can be sure that corrective actions will be effective.
The causal tree is a tool for making visual all of the conditions and factors that enabled the actions, which led to error. This is an important exercise as too often, when looking for causes, a team stops at the first sign of human error. Shame and blame is the initial response to a mistake. However, with the understanding the team gains from this exploration, a more appropriate corrective action is possible–one that will create barriers to human error by correcting the latent conditions and causal factors that influence human behavior.