U.S. Department of Health & Human Services
Root Cause Analysis
PATIENT SAFETY PRIMERS
Root Cause Analysis
Device-related Complications (6)
Diagnostic Errors (12)
Identification Errors (15)
Discontinuities, Gaps, and Hand-Off Problems (12)
Fatigue and Sleep Deprivation (2)
Medication Safety (39)
Medical Complications (14)
Nonsurgical Procedural Complications (7)
Surgical Complications (24)
Transfusion Complications (2)
Psychological and Social Complications (6)
Australia and New Zealand (5)
North America (106)
Journal Article (109)
Newspaper/Magazine Article (11)
Press Release/Announcement (2)
Web Resource (4)
Epidemiology of Errors and Adverse Events (29)
Active Errors (48)
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 (115)
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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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.
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.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.
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.
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 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.
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.
Adverse Health Events in Minnesota: Tenth Annual Public Report.
St. Paul, MN: Minnesota Department of Health; January 2014.
Applying modern error theory to the problem of missed injuries in trauma.
Clarke DL, Gouveia J, Thomson SR, Muckart DJJ. World J Surg. 2008;32:1176-1182.
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2008;43:547-550, 554.
Flying Object Hits MRI.
Gosbee J, Gosbee LL. AHRQ WebM&M [serial online]. February 2003.
The wrong patient.
Chassin MR, Becher EC. Ann Intern Med. 2002;136:826-833.
Environmental Safety in the OR.
Linkin DR, Lautenbach E. AHRQ WebM&M [serial online]. February 2004.
Calland JF. AHRQ WebM&M [serial online]. January 2004.
Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
Conway JB, Weingart SN. AHRQ WebM&M [serial online]. May 2005.
Do Not Disturb!
Duffy FD, Cassel CK. AHRQ WebM&M [serial online]. October 2007.
Double Dosing, by the Rules
Cohen H. AHRQ WebM&M [serial online]. February/March 2009.
Communication errors in dispatch of air medical transport.
Vilensky D, Macdonald RD. Prehosp Emerg Care. 2011;15:39-43.
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.
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