U.S. Department of Health & Human Services
Root Cause Analysis
PATIENT SAFETY PRIMERS
Root Cause Analysis
2014 ANNUAL PERSPECTIVES
Device-related Complications (6)
Diagnostic Errors (12)
Identification Errors (15)
Discontinuities, Gaps, and Hand-Off Problems (14)
Fatigue and Sleep Deprivation (2)
Medication Safety (39)
Medical Complications (16)
Nonsurgical Procedural Complications (7)
Surgical Complications (25)
Transfusion Complications (2)
Psychological and Social Complications (6)
Australia and New Zealand (6)
North America (108)
Journal Article (115)
Newspaper/Magazine Article (11)
Press Release/Announcement (2)
Web Resource (4)
Epidemiology of Errors and Adverse Events (32)
Active Errors (51)
Latent Errors (26)
Near Miss (5)
Approach to Improving Safety
Root Cause Analysis
Allied Health Services (1)
Health Care Providers (101)
Health Care Executives and Administrators (119)
Non-Health Care Professionals (49)
Setting of Care
Psychiatric Facilities (2)
Residential Facilities (3)
Ambulatory Care (10)
Outpatient Surgery (5)
Patient Transport (4)
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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.
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.
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.
Incorrect surgical procedures within and outside of the operating room.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.
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.
The Role of the Patient in Improving Patient Safety
Gibson R. AHRQ WebM&M [serial online]. March 2007.
Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration.
Dunn EJ, Moga PJ. Arch Pathol Lab Med. 2010;134:244-255.
Adverse Health Events in Minnesota: Eleventh Annual Public Report.
St. Paul, MN: Minnesota Department of Health; February 2015.
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.
Wrong-site craniotomy: analysis of 35 cases and systems for prevention.
Cohen FL, Mendelsohn D, Bernstein M. J Neurosurg. 2010;113:461-473.
Double Dosing, by the Rules
Cohen H. AHRQ WebM&M [serial online]. February/March 2009.
Multiple latent failures align to allow a serious drug interaction to harm a patient.
ISMP Medication Safety Alert! Acute Care Edition. May 5, 2011;16:1-3.
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.
Do Not Disturb!
Duffy FD, Cassel CK. AHRQ WebM&M [serial online]. October 2007.
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2008;43:547-550, 554.
Communication errors in dispatch of air medical transport.
Vilensky D, Macdonald RD. Prehosp Emerg Care. 2011;15:39-43.
The wrong patient.
Chassin MR, Becher EC. Ann Intern Med. 2002;136:826-833.
Shaping systems for better behavioral choices: lessons learned from a fatal medication error.
Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.
Calland JF. AHRQ WebM&M [serial online]. January 2004.
Environmental Safety in the OR.
Linkin DR, Lautenbach E. AHRQ WebM&M [serial online]. February 2004.
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