Fault trees uncover complex causes.

Patrice Spath

Newspaper/Magazine Article

Fault trees uncover complex causes.

April 18, 2007

Spath P. Hospital peer review. 2007;32(4):49-52.

View more articles from the same authors.

This article discusses the use of a fault tree diagram to identify root causes of an incident within complex system relationships.

PubMed citation

Related Resources From the Same Author(s)

Don't be fooled by the illusion of patient safety.

May 18, 2005

Ways to avert potential patient care disasters.

October 18, 2006

Procedures should promote patient safety.

August 23, 2006

Manage staff fatigue to improve patient safety.

May 24, 2006

Maintain accountability in patient safety efforts.

October 12, 2005

HIM functions in healthcare quality and patient safety.

August 10, 2011

Patient safety in the ambulatory OB/GYN setting.

August 29, 2012

Cultural transformation toward patient safety: one conversation at a time.

April 16, 2008

Drug administration errors in hospital inpatients: a systematic review.

August 14, 2013

Undiagnosed breast cancer at MR imaging: analysis of causes.

October 10, 2012

A clinical data warehouse-based process for refining medication orders alerts.

October 17, 2012

Diagnostic errors in pediatric radiology.

March 30, 2011

Experience feedback committees: a way of implementing a root cause analysis practice in hospital medical departments.

August 15, 2018

Characteristics of morbidity and mortality conferences associated with the implementation of patient safety improvement initiatives, an observational study.

March 16, 2016

Resident duty hours in surgery for ensuring patient safety, providing optimum resident education and training, and promoting resident well-being: a response from the American College of Surgeons to the Report of the Institute of Medicine, "Resident Duty Hours: Enhancing Sleep, Supervision, and Safety."

September 16, 2009

Parent–provider miscommunications in hospitalized children.

August 23, 2017

Parent-reported errors and adverse events in hospitalized children.

March 16, 2016

Analysis of overridden alerts in a drug–drug interaction detection system.

October 22, 2008

Patient safety and quality outcomes for ED patients admitted to alternative care area inpatient beds.

May 29, 2019

Unit-based care teams and the frequency and quality of physician–nurse communications.

May 11, 2011

Patient safety curriculum for surgical residency programs: results of a national consensus conference.

April 11, 2007

Management of adverse surgical events: a structured education module for residents.

November 2, 2005

Chemotherapeutic errors in hospitalised cancer patients: attributable damage and extra costs.

February 1, 2012

Implementing receiver-driven handoffs to the emergency department to reduce miscommunication.

June 3, 2020

Family safety reporting in hospitalized children with medical complexity.

July 20, 2022

Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study.

November 16, 2022

Related Resources

Redesigning Event Review with RCA2

September 13, 2023 - November 7, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Interview

In Conversation with Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

April 26, 2023

Perspective

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

April 26, 2023

Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery.

October 5, 2022

Rethinking use of air-safety principles to reduce fatal hospital errors.

September 7, 2022

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

July 20, 2022

Anesthesiologist group says hospitals can prevent fatal errors like Vanderbilt's.

June 15, 2022

Adopt strategies to manage look-alike and/or sound-alike medication name mix-ups.

June 15, 2022

At US hospitals, a drug mix-up is just a few keystrokes away.

May 11, 2022

Root cause analysis to identify contributing factors for the development of hospital acquired pressure injuries.

July 7, 2021

To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare.

May 5, 2021

Implementing a human factors approach to RCA(2) : tools, processes and strategies.

March 10, 2021

System factors affecting intraoperative risk and resilience: applying a novel integrated approach to study surgical performance and patient safety.

February 10, 2021

Health information technology-related wrong-patient errors: context is critical.

January 27, 2021

Nurse burnout predicts self-reported medication administration errors in acute care hospitals.

January 20, 2021

Application of human factors methods to understand missed follow-up of abnormal test results.

November 11, 2020

Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse Events.

July 22, 2020

Root cause analysis for hospital-acquired pressure injury.

August 14, 2019

The Swiss Cheese Conference: integrating and aligning quality improvement education with hospital patient safety initiatives.

February 27, 2019

Pro/con debate: color-coded medication labels.

February 20, 2019

Integrating systemic accident analysis into patient safety incident investigation practices.

November 21, 2018

The problem with the '5 whys.'

September 14, 2016

Human factors in healthcare: welcome progress, but still scratching the surface.

June 29, 2016

A new frontier in healthcare risk management: working to reduce avoidable patient suffering.

February 24, 2016

Root Cause Analysis Playbook.

February 17, 2016

Learning from mistakes and near mistakes: using root cause analysis as a risk management tool.

April 22, 2015

'Connecting the dots': leveraging visual analytics to make sense of patient safety event reports.

December 3, 2014

Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia.

July 9, 2014

Randomized crossover study evaluating the effect of a hand sanitizer dispenser on the frequency of hand hygiene among anesthesiology staff in the operating room.

July 2, 2014

See More About The Topic

Hospitals

Risk Managers

Quality and Safety Professionals

Root Cause Analysis

Human Factors Engineering

Fault trees uncover complex causes.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Fault trees uncover complex causes.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

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