An analysis of adverse events in the rehabilitation department: using the Veterans Affairs root cause analysis system.

Gregory W. Hagley; Peter D. Mills; Brian Shiner; Robin R. Hemphill

Study

An analysis of adverse events in the rehabilitation department: using the Veterans Affairs root cause analysis system.

November 14, 2018

Hagley GW, Mills PD, Shiner B, et al. Phys Ther. 2018;98(4):223-230.

View more articles from the same authors.

This analysis of the Veterans Health Administration root cause analysis database identified adverse events that occurred during rehabilitation services, such as physical therapy, occupational therapy, or speech and language therapy. Rehabilitation-related adverse events were extremely rare. The most common incidents were falls and delayed response to clinical deterioration.

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An analysis of adverse events in the rehabilitation department: using the Veterans Affairs root cause analysis system.

Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

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An analysis of adverse events in the rehabilitation department: using the Veterans Affairs root cause analysis system.

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