Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement procedures in the Veterans Health Association.

Christina Soncrant; Peter D. Mills; Julia Neily; Douglas E. Paull; Robin R. Hemphill

Study

Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement procedures in the Veterans Health Association.

March 25, 2020

Soncrant C, Mills PD, Neily J, et al. J Patient Saf. 2020;16(1):41-46.

View more articles from the same authors.

In this retrospective review of root cause analysis (RCA) reports of select gastrointestinal procedures, researchers identified 27 adverse events 30-month period. Nearly half (48%) of events caused major or catastrophic harm. The most frequently reported adverse events were attributable to human factors (22%), medication errors (22%) or retained items; retained items were associated with the most harm.

PubMed citation

Available at

Related Resources From the Same Author(s)

Review of reported adverse events occurring among the homeless veteran population in the Veterans Health Administration.

November 17, 2021

A review of adverse event reports from emergency departments in the Veterans Health Administration.

March 18, 2020

Root cause analysis of adverse events involving opioid overdoses in the Veterans Health Administration.

June 23, 2021

Retrospective analysis of reported suicide deaths and attempts on Veterans Health Administration campuses and inpatient units.

September 23, 2020

Delays in diagnosis, treatment, and surgery: root causes, actions taken, and recommendations for healthcare improvement.

June 1, 2022

Root cause analysis of ICU adverse events in the Veterans Health Administration.

August 30, 2017

Suicide and suicide attempts on hospital grounds and clinic areas.

August 11, 2021

Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration.

November 24, 2021

Veterans Health Administration response to the COVID-19 crisis: surveillance to action.

October 26, 2022

The impact of adverse events on clinicians: what's in a name?

November 22, 2017

A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes.

November 4, 2020

Errors during resuscitation: the impact of perceived authority on delivery of care.

March 25, 2020

Root cause analysis of reported patient falls in ORs in the Veterans Health Administration.

October 24, 2018

Occupational therapy utilization in veterans with dementia: a retrospective review of root cause analyses of falls leading to adverse events.

April 6, 2022

Surgical programs in the Veterans Health Administration maintain briefing and debriefing following medical team training.

April 30, 2014

Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the Veterans Health Administration.

April 29, 2015

Sharing lessons learned to prevent incorrect surgery.

November 21, 2012

Wrong-side thoracentesis: lessons learned from root cause analysis.

July 2, 2014

Data collection for adverse events reporting by US dental schools.

September 30, 2020

Root cause analysis of serious adverse events among older patients in the Veterans Health Administration.

May 28, 2014

Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons learned.

August 23, 2017

Predictors of serious opioid-related adverse drug events in hospitalized patients.

July 8, 2020

A systems approach to analyzing and preventing hospital adverse events.

June 24, 2020

Analysis of risk factors for patient safety events occurring in the emergency department.

October 7, 2020

Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.

December 5, 2018

Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients.

August 21, 2013

Miscarriage treatment-related morbidities and adverse events in hospitals, ambulatory surgery centers, and office-based settings.

December 16, 2020

A machine learning approach to reclassifying miscellaneous patient safety event reports.

July 29, 2020

Sharing lessons learned to prevent adverse events in anesthesiology nationwide.

August 21, 2019

Comparison of a voluntary safety reporting system to a global trigger tool for identifying adverse events in an oncology population.

August 3, 2022

Disparities in adverse event reporting for hospitalized children.

August 3, 2022

Department of Veterans Affairs Chief Resident in Quality and Patient Safety Program: a model to spread change.

June 8, 2016

Learning from incident reporting? Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care.

December 9, 2020

Influence of psychological safety and organizational support on the impact of humiliation on trainee well-being.

June 8, 2022

Patient misidentification events in the Veterans Health Administration: a comprehensive review in the context of high-reliability health care.

October 21, 2020

Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient harm.

July 20, 2022

Association of implementation and social network factors with patient safety culture in medical homes: a coincidence analysis.

September 2, 2020

Defining diagnostic error: a scoping review to assess the impact of the National Academies' report Improving Diagnosis in Health Care.

May 25, 2022

Retained guidewires in the Veterans Health Administration: getting to the root of the problem.

May 9, 2018

Examining causes and prevention strategies of adverse events in deceased hospital patients: a retrospective patient record review study in the Netherlands.

June 16, 2021

Adverse event reporting priorities: an integrative review.

June 29, 2022

A quality improvement initiative to improve patient safety event reporting by residents.

February 9, 2022

Curriculum development and implementation of a national interprofessional fellowship in patient safety.

September 5, 2018

Predictors of successful implementation of preoperative briefings and postoperative debriefings after medical team training.

November 18, 2009

Nursing crew resource management: a follow-up report from the Veterans Health Administration.

March 13, 2013

Simulation-based education enhances patient safety behaviors during central venous catheter placement.

September 15, 2021

Leading causes of anesthesia-related liability claims in ambulatory surgery centers.

October 6, 2021

Personality traits and traumatic outcome symptoms in registered nurses in the aftermath of a patient safety incident.

July 22, 2020

The use of anatomical side markers in general radiology: a systematic review of the current literature.

August 26, 2020

Early warning scores to predict noncritical events overnight in hospitalized medical patients: a prospective case cohort study.

September 23, 2020

Combined proactive risk assessment: unifying proactive and reactive risk assessment techniques in health care.

June 29, 2022

Preventable adverse drug events causing hospitalisation: identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study.

February 24, 2021

The patient died: what about involvement in the investigation process?

June 24, 2020

The patients' perspective: hematological cancer patients' experiences of adverse events as part of care.

August 18, 2021

Race differences in reported "near miss" patient safety events in health care system high reliability organizations.

December 15, 2021

Why an open disclosure procedure is and is not followed after an avoidable adverse event.

September 8, 2021

Nurse-reported bullying and documented adverse patient events: an exploratory study in a US Hospital.

June 24, 2020

Central venous catheter guidewire retention: lessons from England's never event database.

May 4, 2022

Medication errors in anesthesiology: is it time to train by example? Vignettes can assess error awareness, assessment of harm, disclosure, and reporting practices.

October 28, 2020

National and institutional trends in adverse events over time: a systematic review and meta-analysis of longitudinal retrospective patient record review studies.

March 3, 2021

What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports.

May 18, 2022

Association between physician burnout and self-reported errors: meta-analysis.

January 26, 2022

Impact of an obstetrical hospitalist program on the safety events in a mid-sized obstetrical unit.

September 16, 2020

Understanding the "Swiss cheese model" and its application to patient safety.

July 21, 2021

Usability and accessibility of publicly available patient safety databases.

June 1, 2022

The association between health care staff engagement and patient safety outcomes: a systematic review and meta-analysis.

February 3, 2021

Exploring changes in patient safety incidents during the COVID-19 pandemic in a Canadian regional hospital system: a retrospective time series analysis.

February 23, 2022

Triggers contributing to health care clinicians' disruptive behaviors.

September 16, 2020

Suicide attempts and completions on medical-surgical and intensive care units.

January 29, 2014

Potentially severe incidents during interhospital transport of critically ill patients, frequently occurring but rarely reported: a prospective study.

January 19, 2022

The burden of opioid-related adverse drug events on hospitalized previously opioid-free surgical patients.

March 10, 2021

Expert consensus on currently accepted measures of harm.

September 9, 2020

A 6-year thematic review of reported incidents associated with cardiopulmonary resuscitation calls in a United Kingdom hospital.

April 27, 2022

Allergic adverse drug events after alert overrides in hospitalized patients.

September 21, 2022

Evolving factors in hospital safety: a systematic review and meta-analysis of hospital adverse events.

September 29, 2021

Developing and aligning a safety event taxonomy for inpatient psychiatry.

July 13, 2022

Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect?

August 25, 2021

Teamwork before and during COVID-19: the good, the same, and the ugly….

August 24, 2022

Root cause analysis using the prevention and recovery information system for monitoring and analysis method in healthcare facilities: a systematic literature review.

June 8, 2022

Patient harm during COVID-19 pandemic: using a human factors lens to promote patient and workforce safety.

December 23, 2020

Encouraging patients to speak up about problems in cancer care.

January 12, 2022

A systematic review of methods for medical record analysis to detect adverse events in hospitalized patients.

March 2, 2022

Applying decision science to the prioritization of healthcare-associated infection initiatives.

October 27, 2021

When safety event reporting is seen as punitive: "I've been PSN-ed!"

September 9, 2020

Multispecialty physician online survey reveals that burnout related to adverse event involvement may be mitigated by peer support.

May 18, 2022

Using community detection techniques to identify themes in COVID-19-related patient safety event reports.

December 7, 2022

Adverse events in intensive care and continuing care units during bed-bath procedures: the prospective observational NURSIng during critical carE (NURSIE) study.

December 23, 2020

Evaluating patient identification practices during intrahospital transfers: a human factors approach.

March 29, 2023

Postdischarge adverse events among neonates admitted to the neonatal intensive care unit.

September 7, 2022

Morbidity and mortality caused by noncompliance with California hospital licensure: immediate jeopardies in California hospitals, 2007-2017.

March 9, 2022

Health literacy-related safety events: a qualitative study of health literacy failures in patient safety events.

July 28, 2021

Impact of the COVID-19 pandemic on the experiences of hospitalized patients: a scoping review.

February 22, 2023

Critical care simulation education program during the COVID-19 pandemic.

November 10, 2021

Physician reporting of clinically significant events through a computerized patient sign-out system.

September 14, 2011

Factors causing variation in World Health Organization surgical safety checklist effectiveness-a rapid scoping review.

December 14, 2022

Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016

March 3, 2017

Understanding hazards for adverse drug events among older adults after hospital discharge: insights from frontline care professionals.

July 20, 2022

Hearing impairment and the amelioration of avoidable medical error: a cross-sectional survey.

April 28, 2021

Patient safety strategies in psychiatry and how they construct the notion of preventable harm: a scoping review.

November 3, 2021

Using root cause analysis to reduce falls with injury in community settings.

August 1, 2012

Related Resources

Annual Perspective

Equity in Patient Safety

March 27, 2024

Reducing retained foreign objects in the operating room: a quality improvement initiative.

December 20, 2023

WebM&M Cases

The Risks of a Malpositioned Gastrostomy Tube and Poor Communication

November 29, 2023

Patient safety incidents in endoscopy: a human factors analysis of non-procedural significant harm incidents from the National Reporting and Learning System (NRLS).

November 29, 2023

Intraoperative communications between pathologists and surgeons: do we understand each other?

September 6, 2023

Investigation of urology intraoperative events leading to root cause analysis at national VA medical centers.

July 26, 2023

Root causes and preventability of unintentionally retained foreign objects after surgery: a national expert survey from Switzerland.

July 19, 2023

The role of an assistant nurse in implementing the WHO Surgical Safety Checklist: perception and perspectives.

July 5, 2023

Factors contributing to preventing operating room "never events": a machine learning analysis.

May 10, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

An evidence synthesis on perioperative handoffs: a call for balanced sociotechnical solutions.

April 5, 2023

WebM&M Cases

Procedure Complications – Who is Responsible for Follow up?

March 29, 2023

Anesthesia outside of the OR: cause for patient safety concerns?

January 25, 2023

Guidelines in Practice: prevention of unintentionally retained surgical items.

December 7, 2022

A multicenter collaborative effort to reduce preventable patient harm due to retained surgical items.

November 30, 2022

WebM&M Cases

False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.

October 27, 2022

Improving discharge safety in a pediatric emergency department.

October 26, 2022

Analyzing and discussing human factors affecting surgical patient safety using innovative technology: creating a safer operating culture.

August 31, 2022

Preventing retained surgical items.

August 3, 2022

Predictive power of the "trigger tool" for the detection of adverse events in general surgery: a multicenter observational validation study.

March 9, 2022

Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery.

September 22, 2021

WebM&M Cases

Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough

April 28, 2021

A human factors intervention in a hospital--evaluating the outcome of a TeamSTEPPS program in a surgical ward.

April 14, 2021

A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes.

November 4, 2020

Using radiofrequency technology to prevent retained sponges and improve patient outcomes.

October 28, 2020

Patient misidentification events in the Veterans Health Administration: a comprehensive review in the context of high-reliability health care.

October 21, 2020

A qualitative content analysis of retained surgical items: learning from root cause analysis investigations.

May 27, 2020

The impact of surgical count technology on retained surgical items rates in the Veterans Health Administration.

April 22, 2020

Using Safety-II and resilient healthcare principles to learn from Never Events.

April 8, 2020

A review of adverse event reports from emergency departments in the Veterans Health Administration.

March 18, 2020

See More About The Topic

Operating Room

Quality and Safety Professionals

Gastroenterology

Discontinuities, Gaps, and Hand-Off Problems

Gastroenterology

Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement procedures in the Veterans Health Association.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement procedures in the Veterans Health Association.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site