This session will explore how common responses to serious adverse events and subsequent root cause analyses can actually make us less safe by requiring clinicians to create workarounds to complete their work.

• After this presentation you will be able to: • Evaluate your organization’s current response to serious adverse events regarding the likelihood of causing unplanned migrations. • Explain the driving forces that cause migrations.
• Carol Haraden, PhD, Vice President, Institute for Healthcare Improvement; Rene Amalberti, MD, PhD, Professor, Vice CEO, IMASSA-Aerospace Medical Institute