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

Corwin GS, Mills PD, Shanawani H, et al. Root Cause Analysis of ICU Adverse Events in the Veterans Health Administration. The Joint Commission Journal on Quality and Patient Safety. 2017;43(11). doi:10.1016/j.jcjq.2017.04.009.

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August 30, 2017
Corwin GS, Mills PD, Shanawani H, et al. The Joint Commission Journal on Quality and Patient Safety. 2017;43.

Root cause analysis is widely utilized in health care to examine adverse events. In this retrospective study, researchers analyzed root cause analysis reports regarding events related to care in Veterans Health Administration intensive care units over a 2-year period. They found that events frequently had multiple root causes and that action items commonly involved changes to policies, procedures, and processes of care as well as training and education initiatives.

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Corwin GS, Mills PD, Shanawani H, et al. Root Cause Analysis of ICU Adverse Events in the Veterans Health Administration. The Joint Commission Journal on Quality and Patient Safety. 2017;43(11). doi:10.1016/j.jcjq.2017.04.009.