AHRQ Patient Safety Network

The Collection > Root Cause Analysis

PATIENT SAFETY PRIMERS
Root Cause Analysis

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Safety Target

•Device-related Complications (6)

•Diagnostic Errors (15)

•Identification Errors (14)

•Discontinuities, Gaps, and Hand-Off Problems (11)

•Fatigue and Sleep Deprivation (2)

•Medication Safety (37)

•Medical Complications (13)

•Nonsurgical Procedural Complications (5)

•Surgical Complications (23)

•Transfusion Complications (2)

•Psychological and Social Complications (6)

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•Africa (2)

•Asia (2)

•Australia and New Zealand (5)

Resource Types

•Journal Article (107)

•Legislation/Regulation (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (9)

•Press Release/Announcement (2)

•Special or Theme Issue (1)

•Web Resource (6)

Error Types

•Epidemiology of Errors and Adverse Events (28)

•Active Errors (35)

•Latent Errors (22)

•Near Miss (6)

Approach to Improving Safety
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Root Cause Analysis

Clinical Areas

•Allied Health Services (1)

•Medicine (72)

•Nursing (9)

•Pharmacy (8)

Target Audience

•Health Care Providers (92)

•Health Care Executives and Administrators (114)

•Non-Health Care Professionals (52)

•Patients (7)

Setting of Care

•Hospitals (71)

•Psychiatric Facilities (2)

•Residential Facilities (3)

•Ambulatory Care (8)

•Outpatient Surgery (5)

•Patient Transport (4)

1 - 20 of 134

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STUDY

Incorrect surgical procedures within and outside of the operating room: a follow-up report.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146 1235-1239.

STUDY

Incorrect surgical procedures within and outside of the operating room.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.

STUDY

Preventing wrong site, procedure, and patient events using a common cause analysis.

Mallett R, Conroy M, Saslaw LZ, Moffatt-Bruce S. Am J Med Qual. 2012;27:21-29.

STUDY

Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences.

Stahel PF, Sabel AL, Victoroff MS, et al. Arch Surg. 2010;145:978-984.

MULTI-USE WEBSITE

Medical error.

Wikipedia.

STUDY

Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study.

Cohen SP, Hayek SM, Datta S, et al. Anesthesiology. 2010;112:711-718.

STUDY

Wrong-site craniotomy: analysis of 35 cases and systems for prevention.

Cohen FL, Mendelsohn D, Bernstein M. J Neurosurg. 2010;113:461-473.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010:45;352-355.

STUDY

What’s past is prologue: organizational learning from a serious patient injury.

Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.

STUDY

Assessment of latent factors contributing to error: addressing surgical pathology error wisely.

Smith ML, Raab SS. Arch Pathol Lab Med. 2011;135:1436-1440.

COMMENTARY

Root cause analysis of transfusion error: identifying causes to implement changes.

Elhence P, Veena S, Sharma RK, Chaudhary RK. Transfusion. 2010;50:2772-2777.

STUDY

Communication errors in dispatch of air medical transport.

Vilensky D, Macdonald RD. Prehosp Emerg Care. 2011;15:39-43.

STUDY

Systemic vulnerabilities to suicide among veterans from the Iraq and Afghanistan conflicts: review of case reports from a national Veterans Affairs database.

Mills PD, Huber SJ, Vince Watts B, Bagian JP. Suicide Life Threat Behav. 2011;41:21-32.

STUDY

Nature, causes and consequences of unintended events in surgical units.

van Wagtendonk I, Smits M, Merten H, Heetveld MJ, Wagner C. Br J Surg. 2010;97:1730-1740.

STUDY

Towards safer neonatal transfer: the importance of critical incident review.

Moss SJ, Embleton ND, Fenton AC. Arch Dis Child. 2005;90:729-732.

STUDY

Preventable morbidity at a mature trauma center.

Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144:536-541.

COMMENTARY

Flying Object Hits MRI.

Gosbee J, Gosbee LL. AHRQ WebM&M [serial online]. February 2003.

STUDY

Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme.

Braithwaite J, Westbrook MT, Mallock NA, Travaglia JF, Iedema RA. Qual Saf Health Care. 2006;15:393-399.

STUDY

Anatomic pathology databases and patient safety.

Raab SS, Grzybicki DM, Zarbo RJ, Meier FA, Geyer SJ, Jensen C. Arch Pathol Lab Med. 2005;129:1246-1251.

STUDY

Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis.

Hofer TP, Hayward RA. Ann Intern Med. 2002;137(pt 1):327-333.

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