Avoid Band-Aid Solutions: Strengthening Adverse Event Investigations

03/09/15  Portland, Ore.

If you missed this training last fall, don’t miss out again on what others have found to be incredibly valuable!

Get the most out of your event investigations by attending this one-day course on identifying the causes and contributing factors of system failures and developing strong action plans. Learn root cause identification strategies to ensure that your organization is effectively analyzing underlying systems to determine where changes might reduce risk. Then hone your skills at developing strong, system-level action plans that ensure your investigations result in preventing similar adverse events in the future.

Regardless of the healthcare setting in which you work, if you are a healthcare professional who is responsible for the analysis and internal or external reporting of adverse events, this training can help you increase the value of your investigations of serious, less serious, and near miss events. By attending this training and strengthening your investigations, you can increase the quality of care you provide and decrease costs associated with repeated adverse events and re-admissions.

March 19, 2015
8:00am - 3:30pm
Ambridge Event Center, Portland, OR


Upon completion of the training, participants will be able to:

  • Differentiate between system-focused and individual-focused approaches
  • Use common root cause analysis tools such as cause-effect diagrams and 5 Whys
  • Identify root causes of events
  • Develop and implement strong action plans


Who Should Attend

This course is designed for healthcare professionals involved in patient safety and adverse event investigation from hospitals, nursing facilities, dialysis facilities, community pharmacies, and ambulatory surgery centers.

Enrollment Fee

$50 includes lunch and materials.

Continuing Education

Provider approved by the California Board of Registered Nursing, Provider Number 16180 for 7.4 contact hours.
Nursing facility administrator continuing education credits also available.

Directions and Parking

Click here for driving directions and parking information for the Ambridge Event Center. Complimentary parking is available on a first come, first served basis.

Note: The Commission offers the Avoid Band-Aid Solutions trainings on a quarterly basis. The next training will be held outside the Portland Metro area- exact location to be determined.


Contact us at 503-928-6158 or