Building safer systems through critical occurrence reviews: nine years of learning.

Polly Stevens; Janice Campbell; Lynn Urmson; Rita Damignani

Study

Building safer systems through critical occurrence reviews: nine years of learning.

November 10, 2010

Stevens P, Campbell J, Urmson L, et al. Healthc Q. 2010;13 Spec No:74-80.

View more articles from the same authors.

This article describes how a children's hospital used root cause analysis to drive improvements in patient safety.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Operational failures detected by frontline acute care nurses.

July 5, 2017

Adverse events among children in Canadian hospitals: the Canadian Paediatric Adverse Events Study.

January 25, 2017

A 7-year analysis of attributable costs of healthcare-associated infections in a network of community hospitals in the southeastern United States.

January 31, 2024

Improving employee voice about transgressive or disruptive behavior: a case study.

April 17, 2019

Hospital rules-based system: the next generation of medical informatics for patient safety.

February 27, 2009

Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review.

December 16, 2020

Identifying 'avoidable harm' in family practice: a RAND/UCLA Appropriateness Method consensus study.

November 13, 2019

Defining avoidable healthcare-associated harm in prisons: a mixed-method development study.

April 19, 2023

Redesigning rounds in the ICU: standardizing key elements improves interdisciplinary communication.

October 3, 2018

Patient safety in actioning and communicating blood test results in primary care: a UK wide audit using the Primary Care Academic CollaboraTive (PACT).

October 2, 2024

Related Resources

Adverse events and patient outcomes among hospitalized children cared for by general pediatricians vs hospitalists.

January 17, 2019

Racial, ethnic, and socioeconomic disparities in patient safety events for hospitalized children.

December 19, 2018

Family-centered rounds on pediatric wards: a PRIS network survey of US and Canadian hospitalists.

November 23, 2016

Application of a theoretical framework for behavior change to hospital workers' real-time explanations for noncompliance with hand hygiene guidelines.

February 6, 2014

Incidence of potentially avoidable urgent readmissions and their relation to all-cause urgent readmissions.

October 31, 2011

Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety.

October 21, 2011

Using prospective clinical surveillance to identify adverse events in hospital.

August 25, 2011

Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.

October 30, 2010

Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.

November 12, 2008

Perspective

What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation?

September 1, 2006

See More About The Topic

Children's Hospitals

Quality and Safety Professionals

General Internal Medicine

Hospital Medicine

Identification Errors

Building safer systems through critical occurrence reviews: nine years of learning.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Building safer systems through critical occurrence reviews: nine years of learning.

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

Submit Your Training

Continue as a Guest

Continue Logged In

Submit Your Training

Continue as a Guest

Continue Logged In

New Users to the PSNet site

Submit Your Toolkit

Continue as a Guest

Continue Logged In

Submit Your Toolkit

Continue as a Guest

Continue Logged In

New Users to the PSNet site

Submit Your WebM&M Case

Continue as a Guest

Continue Logged In

Submit Your WebM&M Case

Continue as a Guest

Already have a PSNet

Account?

New Users