In a large healthcare organization, individual medical facilities have the opportunity to learn from each other, correcting process vulnerabilities proactively without actually experiencing the error. The work represented here is an effort to capitalize on the size of the VA healthcare system to inform proactive process improvement efforts at VA facilities with reactive event report data from the entire VA system. We seek to do this by mapping event reports to the steps of a process, and examining the parts of sub-processes prone to failure in order to understand how and why it failed. This allows an individual medical facility to learn from previous process failures and make corrections.
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