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 (10)

•Identification Errors (11)

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

•Fatigue and Sleep Deprivation (1)

•Medication Safety (29)

•Medical Complications (6)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (11)

•Transfusion Complications (1)

•Psychological and Social Complications (4)

Origin/Sponsor

•Africa (1)

•Australia and New Zealand (3)

Resource Types

•Journal Article (60)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (10)

•Tools/Toolkit (1)

•Web Resource (3)

Error Types

•Epidemiology of Errors and Adverse Events (28)

•Active Errors (22)

•Latent Errors (10)

•Near Miss (3)

Approach to Improving Safety
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Root Cause Analysis

Clinical Areas

•Medicine (40)

•Nursing (3)

•Pharmacy (10)

Target Audience

•Health Care Providers (49)

•Health Care Executives and Administrators (62)

•Non-Health Care Professionals (32)

•Patients (7)

Setting of Care

•Hospitals (53)

•Psychiatric Facilities (2)

•Residential Facilities (2)

•Ambulatory Care (7)

•Outpatient Surgery (5)

•Patient Transport (2)

1 - 20 of 80

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STUDY

Using root cause analysis to reduce falls with injury in the psychiatric unit.

Lee A, Mills PD, Watts BV. Gen Hosp Psychiatry. 2012;34:304-311.

NEWSPAPER/MAGAZINE ARTICLE

Fluorouracil error ends tragically, but application of lessons learned will save lives.

ISMP Medication Safety Alert! Acute Care Edition. September 20, 2007;12:1-3.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:547-550, 554.

STUDY

A cross-sectional study on the relationship between utilization of root cause analysis and patient safety at 139 Department of Veterans Affairs medical centers.

Percarpio KB, Watts V. Jt Comm J Qual Patient Saf. 2013;39:32-37.

STUDY

Communication errors in dispatch of air medical transport.

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

STUDY

Unexpected hypoglycemia in a critically ill patient.

Bates DW. Ann Intern Med. 2002;137:110-116.

STUDY

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.

ORGANIZATIONAL POLICY/GUIDELINES

VHA National Patient Safety Improvement Handbook.

Washington, DC: Veterans Health Administration; March 4, 2011.

STUDY

Follow-up study of medication errors reported to the Vaccine Adverse Event Reporting System (VAERS).

Varricchio F, Reed J, and the VAERS Working Group. South Med J. 2006;99:486-489.

COMMENTARY

Lean Six Sigma reduces medication errors.

Esimai G. Qual Prog. April 2005;38:51-57.

BOOK/REPORT

Adverse Health Events in Minnesota: Ninth Annual Public Report.

St. Paul, MN: Minnesota Department of Health; January 2013.

MULTI-USE WEBSITE

National Center for Patient Safety (NCPS).

Department of Veterans Affairs (VA), PO Box 486, Ann Arbor, MI 48106-0486.

COMMENTARY

In Conversation with...Diane Rydrych, MA

Rydrych D. AHRQ WebM&M [serial online]. June 2007.

COMMENTARY

Nursing student medication errors: a case study using root cause analysis.

Dolansky MA, Druschel K, Helba M, Courtney K. J Prof Nurs. 2013;29:102-108.

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

Systematic root cause analysis of adverse drug events in a tertiary referral hospital.

Rex JH, Turnbull JE, Allen SJ, Vande Voorde K, Luther K. Jt Comm J Qual Improv. 2000;26:563-575.

STUDY

Medication errors in the outpatient setting: classification and root cause analysis.

Friedman AL, Geoghegan SR, Sowers NM, Kulkarni S, Formica RN Jr. Arch Surg. 2007;142:278-283.

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.

NEWSPAPER/MAGAZINE ARTICLE

Fault trees uncover complex causes.

Spath P. Hosp Peer Review. April 2007;32:49-52.

NEWSPAPER/MAGAZINE ARTICLE

State starts project to track serious hospital mistakes.

Colburn D. The Oregonian. February 1, 2006:B1.

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