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Collaborative case review: a systems-based approach to patient safety event investigation and analysis.

Lacson R, Khorasani R, Fiumara K, et al. Collaborative case review: a systems-based approach to patient safety event investigation and analysis. J Patient Saf. 2022;18(2):e522-e527. doi: 10.1097/pts.0000000000000857

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March 30, 2022
Lacson R, Khorasani R, Fiumara K, et al. J Patient Saf. 2022;18(2):e522-e527.

Root cause analysis is a commonly used tool to identify systems-related factors that contributed to an adverse event. This study assessed a system-based approach, (i.e., collaborative case reviews (CCR) co-led by radiology and an institutional patient safety program) to identify contributing factors and explore the strength of recommended actions in the radiology department at a large academic medical center. Stronger action items, such as standardization of processes, were implemented in 41% of events, and radiology had higher completion rates than other hospital departments.

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Lacson R, Khorasani R, Fiumara K, et al. Collaborative case review: a systems-based approach to patient safety event investigation and analysis. J Patient Saf. 2022;18(2):e522-e527. doi: 10.1097/pts.0000000000000857