AHRQ Patient Safety Network

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PATIENT SAFETY PRIMERS
Root Cause Analysis

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Safety Target

•Device-related Complications (6)

•Diagnostic Errors (7)

•Identification Errors (10)

•Discontinuities, Gaps, and Hand-Off Problems (5)

•Fatigue and Sleep Deprivation (1)

•Medication Safety (31)

•Medical Complications (9)

•Nonsurgical Procedural Complications (7)

•Surgical Complications (15)

•Psychological and Social Complications (2)

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•Asia (1)

•Australia and New Zealand (2)

Resource Types

•Journal Article (86)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (16)

•Press Release/Announcement (2)

•Tools/Toolkit (1)

•Web Resource (4)

Error Types

•Epidemiology of Errors and Adverse Events (18)

•Active Errors (25)

•Latent Errors (16)

•Near Miss (3)

Approach to Improving Safety
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Root Cause Analysis

Clinical Areas

•Medicine (55)

•Nursing (9)

•Pharmacy (11)

Target Audience

•Health Care Providers (77)

•Health Care Executives and Administrators (99)

•Non-Health Care Professionals (44)

•Patients (10)

Setting of Care

•Hospitals (54)

•Psychiatric Facilities (1)

•Residential Facilities (3)

•Ambulatory Care (9)

•Outpatient Surgery (3)

•Patient Transport (3)

1 - 20 of 119

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NEWSPAPER/MAGAZINE ARTICLE

How hepatitis probe led to clinic: old-fashioned legwork yielded clues that came together.

Allen M. Las Vegas Sun. March 2, 2008.

STUDY

Preventable morbidity at a mature trauma center.

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

REVIEW

Medical error and human factors engineering: where are we now?

Gawron VJ, Drury CG, Fairbanks RJ, Berger RC. Am J Med Qual. 2006;21:57-67.

STUDY

Patient safety in trauma: maximal impact management errors at a level I trauma center.

Ivatury RR, Guilford K, Malhotra AK, Duane T, Aboutanos M, Martin N. J Trauma. 2008;64:265-272.

NEWSPAPER/MAGAZINE ARTICLE

Confronting management errors.

Hofmann PB. Hospitals & Health Networks (H&HN OnLine). June 28, 2005.

COMMENTARY

Computer visualisation of patient safety in primary care: a systems approach adapted from management science and engineering.

Singh R, Singh A, Fox C, Seldan Taylor J, Rosenthal T, Singh G. Inform Prim Care. 2005;13:135-144.

COMMENTARY

Environmental Safety in the OR.

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

PRESS RELEASE/ANNOUNCEMENT

Patient Safety Improvement Corps: An AHRQ/VA partnership.

Rockville, MD: Agency for Healthcare Research and Quality; March 2007.

STUDY

Closing the loop: follow-up and feedback in a patient safety program.

Gandhi TK, Graydon-Baker E, Neppl Huber C, Whittemore AD, Gustafson M. Jt Comm J Qual Patient Saf. 2005;31:614-621.

COMMENTARY

Using medical-error reporting to drive patient safety efforts.

Stow J. AORN J. 2006;84:406-408, 411-414, 417-420.

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.

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.

AWARD RECIPIENT

Promoting collaboration and transparency in patient safety.

Apold J, Daniels T, Sonneborn M. Jt Comm J Qual Patient Saf. 2006;32:672-675.

COMMENTARY

The Role of the Patient in Improving Patient Safety

Gibson R. AHRQ WebM&M [serial online]. March 2007.

COMMENTARY

Developing a medication patient safety program — infrastructure and strategy.

Mark SM, Weber RJ. Hosp Pharm. 2007;42:149-156.

BOOK/REPORT

What Every Health Care Organization Should Know about Sentinel Events.

McKee J, ed. Oakbrook Terrace, IL: Joint Commission Resources; 2005. ISBN: 0866889116.

COMMENTARY

ISMP medication error report analysis.

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

BOOK/REPORT classic

Serious Reportable Events in Healthcare—2011 Update.

Washington, DC: National Quality Forum; 2011. ISBN: 9780982842188.

STUDY

Using patient safety morbidity and mortality conferences to promote transparency and a culture of safety.

Szekendi MK, Barnard C, Creamer J, Noskin GA. Jt Comm J Qual Patient Saf. 2010;36:3-9, AP1-AP2.

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.

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