AHRQ Patient Safety Network

The Collection > Root Cause Analysis

PATIENT SAFETY PRIMERS
Root Cause Analysis

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Safety Target

•Device-related Complications (4)

•Diagnostic Errors (4)

•Identification Errors (2)

•Discontinuities, Gaps, and Hand-Off Problems (2)

•Medication Safety (9)

•Medical Complications (4)

•Nonsurgical Procedural Complications (8)

•Surgical Complications (4)

•Psychological and Social Complications (1)

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•Africa (1)

•Australia and New Zealand (1)

•Europe (13)

•North America (20)

Resource Types

•Journal Article (31)

•Newspaper/Magazine Article (4)

•Web Resource (3)

Error Types

•Epidemiology of Errors and Adverse Events (4)

•Active Errors (9)

•Latent Errors (6)

•Near Miss (2)

Approach to Improving Safety
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Root Cause Analysis

Clinical Areas

•Medicine (27)

•Nursing (2)

•Pharmacy (1)

Target Audience

•Health Care Providers (29)

•Health Care Executives and Administrators (29)

•Non-Health Care Professionals (12)

•Patients (1)

Setting of Care

•Hospitals (18)

•Ambulatory Care (4)

•Outpatient Surgery (2)

•Patient Transport (1)

1 - 20 of 38

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STUDY

Identification of root causes for emergency diagnostic imaging delays at three Canadian hospitals.

Worster A, Fernandes CM, Malcolmson C, Eva K, Simpson D. J Emerg Nurs. 2006;32:276-280.

STUDY

Missed lesions at abdominal oncologic CT: lessons learned from quality assurance.

Siewert B, Sosna J, McNamara A, Raptopoulos V, Kruskal JB. Radiographics. 2008;28:623-638.

COMMENTARY

Managing an acute adverse event in a radiology department.

Kruskal JB, Siewert B, Anderson SW, Eisenberg RL, Sosna J. Radiographics. 2008;28:1237-1250.

NEWSPAPER/MAGAZINE ARTICLE

Forgotten but not gone: tourniquets left on patients.

PA-PSRS Patient Saf Advis. June 2005;2:19-21.

NEWSPAPER/MAGAZINE ARTICLE

Fallible medicine: responding to errors in emergency care.

Whitehead S. Emergency Medical Services. July 2007.

REVIEW

Non-technical skills in the intensive care unit.

Reader T, Flin R, Lauche K, Cuthbertson BH. Br J Anaesth. 2006;96:551-59.

COMMENTARY

Root cause analysis.

Stecker MS. J Vasc Interv Radiol. 2007;18:5-8.

STUDY

The long road to patient safety: a status report on patient safety systems.

Longo DR, Hewett JE, Ge B, Schubert S. JAMA. 2005;294:2858-2865.

COMMENTARY classic

The wrong patient.

Chassin MR, Becher EC. Ann Intern Med. 2002;136:826-833.

COMMENTARY

Getting to the Root of the Matter

Flanders SA, Saint S. AHRQ WebM&M [serial online]. June 2005.

NEWSPAPER/MAGAZINE ARTICLE

Taking risky business out of the MRI suite.

Rozovsky FA, Gilk TB, Latino RJ. Mater Manag Health Care. 2006;15:18-23.

COMMENTARY

Environmental Safety in the OR.

Linkin DR, Lautenbach E. AHRQ WebM&M [serial online]. February 2004.

STUDY

Utility of an online medication-error-reporting system.

Savage SW, Schneider PJ, Pedersen CA. Am J Health Syst Pharm. 2005;62:2265-2270.

REVIEW

Patient safety systems in the primary health care of diabetes—a story of missed opportunities?

Taub N, Baker R, Khunti K, et al. Diabet Med. 2010;27:1322-1326.

STUDY

Training health care professionals in root cause analysis: a cross-sectional study of post-training experiences, benefits and attitudes.

Bowie P, Skinner J, de Wet C. BMC Health Serv Res. 2013;13:50.

COMMENTARY

Learning and sharing safety lessons to improve patient care.

Woodward S. Nurs Stand. January 11-17, 2006;20:49-53.

STUDY

Survey evaluation of the National Patient Safety Agency’s Root Cause Analysis training programme in England and Wales: knowledge, beliefs and reported practices.

Wallace LM, Spurgeon P, Adams S, Earll L, Bayley J. Qual Saf Health Care. 2009;18:288-291.

STUDY

Diagramming patients' views of root causes of adverse drug events in ambulatory care: an online tool for planning education and research.

Brown M, Frost R, Ko Y, Woosley R. Patient Educ Couns. 2006;62:302-315.

STUDY

Incidence and causes of critical incidents in emergency departments: a comparison and root cause analysis.

Thomas M, Mackway-Jones K. Emerg Med J. 2008;25:346-350.

COMMENTARY

It's All in the Syringe

Weingart SN. AHRQ WebM&M [serial online]. August 2006.

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