Root cause analysis using the prevention and recovery information system for monitoring and analysis method in healthcare facilities: a systematic literature review.

Babiche E.J.M Driesen; Mees Baartmans; Hanneke Merten; René H J Otten; Camilla Walker; Prabath W.B Nanayakkara; Cordula Wagner

Review

Root cause analysis using the prevention and recovery information system for monitoring and analysis method in healthcare facilities: a systematic literature review.

June 8, 2022

Driesen BEJM, Baartmans M, Merten H, et al. J Patient Saf. 2022;18(4):342-350.

View more articles from the same authors.

Root cause analysis (RCA) is widely used to investigate, monitor, and learn from unintended events (UE). One method of RCA is the Prevention and Recovery Information System for Monitoring and Analysis (PRISMA)-method. This review identified 25 studies that used the PRISMA method to analyze UEs. Combining record reviews with provider interviews and using multiple PRISMA-trained researchers may increase the number of causes identified.

PubMed citation

Free full text

Related Resources From the Same Author(s)

What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports.

May 18, 2022

Examining causes and prevention strategies of adverse events in deceased hospital patients: a retrospective patient record review study in the Netherlands.

June 16, 2021

The incidence and preventability of adverse events in older acutely admitted patients: a longitudinal study with 4292 patient records.

April 14, 2021

Monitoring preventable adverse events and near misses: number and type identified differ depending on method used.

June 29, 2022

Preventing medication errors in pediatric anesthesia: a systematic scoping review.

November 9, 2022

Delayed recognition of deterioration of patients in general wards is mostly caused by human related monitoring failures: a root cause analysis of unplanned ICU admissions.

September 7, 2016

Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration.

November 24, 2021

Impact of teamwork and communication training interventions on safety culture and patient safety in emergency departments: a systematic review.

January 26, 2022

Addressing patient safety hazards using critical incident reporting in hospitals: a systematic review.

January 18, 2023

Occupational therapy utilization in veterans with dementia: a retrospective review of root cause analyses of falls leading to adverse events.

April 6, 2022

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

March 30, 2022

The use of anatomical side markers in general radiology: a systematic review of the current literature.

August 26, 2020

Factors influencing medication errors in the prehospital paramedic environment: a mixed method systematic review.

July 27, 2022

A systematic review of methods for medical record analysis to detect adverse events in hospitalized patients.

March 2, 2022

Evaluating the impact of radio frequency identification retained surgical instruments tracking on patient safety: literature review.

August 18, 2021

Delays in diagnosis, treatment, and surgery: root causes, actions taken, and recommendations for healthcare improvement.

June 1, 2022

Adverse event reporting priorities: an integrative review.

June 29, 2022

Patient safety and legal regulations: a total-scale analysis of the scientific literature.

October 19, 2022

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

July 20, 2022

Association between physician burnout and self-reported errors: meta-analysis.

January 26, 2022

An international perspective on definitions and terminology used to describe serious reportable patient safety incidents: a systematic review.

December 8, 2021

Morbidity and mortality caused by noncompliance with California hospital licensure: immediate jeopardies in California hospitals, 2007-2017.

March 9, 2022

Is there a mismatch between the perspectives of patients and regulators on healthcare quality? A survey study.

October 6, 2021

The barriers and enhancers to trust in a just culture in hospital settings: a systematic review.

August 17, 2022

Factors causing variation in World Health Organization surgical safety checklist effectiveness-a rapid scoping review.

December 14, 2022

Evolving factors in hospital safety: a systematic review and meta-analysis of hospital adverse events.

September 29, 2021

Patient perceptions of hospital experiences: implications for innovations in patient safety.

March 16, 2022

Analysis of readmissions in a mobile integrated health transitional care program using root cause analysis and common cause analysis.

May 25, 2022

A retrospective review of serious surgical incidents in 5 large UK teaching hospitals: a system-based approach.

June 15, 2022

Differences between methods of detecting medication errors: a secondary analysis of medication administration errors using incident reports, the Global Trigger Tool method, and observations.

June 24, 2020

Registered nurses' and medical doctors' experiences of patient safety in health information exchange during interorganizational care transitions: a qualitative review.

November 10, 2021

Safe handover.

November 22, 2017

Resident and family engagement in medication management in aged care facilities: a systematic review.

July 7, 2021

The morbidity and mortality conference: opportunities for enhancing patient safety.

February 9, 2022

Patient safety issues from information overload in electronic medical records.

September 14, 2022

Patient safety monitoring in acute care in a decentralized national health care system: conceptual framework and initial set of actionable indicators.

July 28, 2021

Ethical issues in patient safety research: a systematic review of the literature.

September 9, 2015

Test-retest reliability of an experienced Global Trigger Tool review team.

October 27, 2021

Pediatric trainee perspectives on the decision to disclose medical errors.

March 30, 2022

Compelled disclosure of confidential information in patient safety research.

April 21, 2021

Patient safety strategies in psychiatry and how they construct the notion of preventable harm: a scoping review.

November 3, 2021

Scale, nature, preventability and causes of adverse events in hospitalised older patients.

February 27, 2013

Characteristics of critical incident reporting systems in primary care: an international survey.

January 19, 2022

Allergic adverse drug events after alert overrides in hospitalized patients.

September 21, 2022

A longitudinal evaluation of computed tomography radiation incidents within a multisite NHS trust.

November 9, 2022

Frequency and nature of communication and handoff failures in medical malpractice claims.

April 6, 2022

Lessons learned in implementing a chronic opioid therapy management system.

December 21, 2022

Interventions into reliability-seeking health care organizations: a systematic review of their goals and measuring methods.

November 30, 2022

Medication safety in mental health hospitals: a mixed-methods analysis of incidents reported to the National Reporting and Learning System.

August 4, 2021

National and institutional trends in adverse events over time: a systematic review and meta-analysis of longitudinal retrospective patient record review studies.

March 3, 2021

Scientific view of the global literature on medical error reporting and reporting systems from 1977 to 2021: a bibliometric analysis.

November 16, 2022

Using the Generic Analysis Method to analyze sentinel event reports across hospitals: a retrospective cross-sectional study.

April 12, 2023

High-risk medication in home care nursing: a Delphi study.

September 7, 2022

Toward constructive change after making a medical error: recovery from situations of error theory as a psychosocial model for clinician recovery.

August 10, 2022

Improving allergy documentation: a retrospective electronic health record system-wide patient safety initiative.

January 1, 2022

Strength of improvement recommendations from injurious fall investigations: a retrospective multi-incident analysis.

April 13, 2022

Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs.

March 2, 2022

Strength of safety measures introduced by medical practices to prevent a recurrence of patient safety incidents: an observational study.

September 7, 2022

Intersystem medical error discovery: a document analysis of ethical guidelines.

January 12, 2022

Engaging patients in the use of real-time electronic clinical data to improve the safety and reliability of their own care.

May 4, 2022

Postdischarge adverse events among neonates admitted to the neonatal intensive care unit.

September 7, 2022

Safety culture, safety climate, and safety performance in healthcare facilities: a systematic review.

January 19, 2022

What do patients and their carers do to support the safety of cancer treatment and care? A scoping review.

December 14, 2022

The impact of the built environment on patient falls in hospital rooms: an integrative review.

June 16, 2021

Room of hazards: a comparison of differences in safety hazard recognition among various hospital-based healthcare professionals and trainees in a simulated patient room.

July 27, 2022

Multifactorial interventions to reduce duration and variability in delays to identification of serious injury after falls in hospital inpatients.

April 27, 2022

Communication during interhospital transfers of emergency general surgery patients: a qualitative study of challenges and opportunities.

October 26, 2022

Feelings of trust and of safety are related facets of the patient's experience in surgery: a descriptive qualitative study in 80 patients.

August 24, 2022

Analysis of risk factors for patient safety events occurring in the emergency department.

October 7, 2020

Impact of unacceptable behaviour between healthcare workers on clinical performance and patient outcomes: a systematic review.

February 16, 2022

Implementing high-reliability organization principles into practice: a rapid evidence review.

November 11, 2020

Preferences and perceptions of medical error disclosure among marginalized populations: a narrative review.

August 10, 2022

Ambulatory virtual care during a pandemic: patient safety considerations.

March 9, 2022

Defining diagnostic error: a scoping review to assess the impact of the National Academies' report Improving Diagnosis in Health Care.

May 25, 2022

A 6-year thematic review of reported incidents associated with cardiopulmonary resuscitation calls in a United Kingdom hospital.

April 27, 2022

Developing and aligning a safety event taxonomy for inpatient psychiatry.

July 13, 2022

Toward zero harm: Mackenzie Health's journey toward becoming a high reliability organization and eliminating avoidable harm.

November 16, 2022

A systems approach to analyzing and preventing hospital adverse events.

June 24, 2020

Expert consensus on currently accepted measures of harm.

September 9, 2020

Unit-based incident reporting and root cause analysis: variation at three hospital unit types.

August 17, 2016

Descriptive analysis of patient misidentification from incident report system data in a large academic hospital federation.

October 20, 2021

The impact of hospital accreditation on the quality of healthcare: a systematic literature review.

October 27, 2021

Safety of elderly fallers: identifying associated risk factors for 30-day unplanned readmissions using a clinical data warehouse.

April 20, 2022

Causes of use errors in ventilation devices--systematic review.

November 10, 2021

Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement procedures in the Veterans Health Association.

March 25, 2020

Why is patient safety a challenge? Insights from the Professionalism Opinions of Medical Students' research.

November 2, 2022

The trigger tool as a method to measure harmful medication errors in children.

May 13, 2015

The impact of electronic communication of medication discontinuation (CancelRx) on medication safety: a pilot study.

October 5, 2022

Influence of psychological safety and organizational support on the impact of humiliation on trainee well-being.

June 8, 2022

Near miss research in the healthcare system: a scoping review.

May 25, 2022

Leading causes of anesthesia-related liability claims in ambulatory surgery centers.

October 6, 2021

Root cause analysis of adverse events involving opioid overdoses in the Veterans Health Administration.

June 23, 2021

Impact of the COVID-19 pandemic on the experiences of hospitalized patients: a scoping review.

February 22, 2023

The analysis of hospital readmission rates after the implementation of hospital readmissions reduction program.

April 13, 2022

Central venous catheter guidewire retention: lessons from England's never event database.

May 4, 2022

In situ simulation for adoption of new technology to improve sepsis care in rural emergency departments.

June 22, 2022

Healing our own: a randomized trial to assess benefits of peer support.

February 2, 2022

Technology-based closed-loop tracking for improving communication and follow-up of pathology results.

February 2, 2022

Patient safety measurement tools used in nursing homes: a systematic literature review.

December 7, 2022

Diagnostic errors in pediatric critical care: a systematic review.

April 28, 2021

Related Resources

An integrative systematic review of employee silence and voice in healthcare: what are we really measuring.

June 28, 2023

Room of horrors simulation in healthcare education: a systematic review.

June 21, 2023

Clinical nurse competence and its effect on patient safety culture: a systematic review.

June 7, 2023

The association between patient safety culture and adverse events - a scoping review.

May 17, 2023

Systematic review of clinical debriefing tools: attributes and evidence for use.

April 19, 2023

Exploration of ward-based nurses' perspectives on their preparedness to recognize clinical deterioration: a scoping review.

March 29, 2023

For children admitted to hospital, what interventions improve medication safety on ward rounds?

March 1, 2023

A scoping review of adverse incidents research in aged care homes: learnings, gaps, and challenges.

February 8, 2023

The value of learning from near misses to improve patient safety: a scoping review.

January 25, 2023

Addressing patient safety hazards using critical incident reporting in hospitals: a systematic review.

January 18, 2023

Structural racism and adverse maternal health outcomes: a systematic review.

December 21, 2022

Prevalence, causes and severity of medication administration errors in the neonatal intensive care unit: a systematic review and meta-analysis.

December 14, 2022

Factors causing variation in World Health Organization surgical safety checklist effectiveness-a rapid scoping review.

December 14, 2022

Conceptual and practical challenges associated with understanding patient safety within community-based mental health services.

December 7, 2022

Scientific view of the global literature on medical error reporting and reporting systems from 1977 to 2021: a bibliometric analysis.

November 16, 2022

The neglected barrier to medication use: a systematic review of difficulties associated with opening medication packaging.

November 16, 2022

Dedicated teams to optimize quality and safety of surgery: a systematic review.

November 16, 2022

A systematic review of nursing practice workarounds.

October 19, 2022

Investigation of interventions to reduce nurses' medication errors in adult intensive care units: a systematic review.

October 12, 2022

Recommendations for the safety of hospitalised patients in the context of the COVID-19 pandemic: a scoping review.

October 5, 2022

The impact of electronic health record interoperability on safety and quality of care in high-income countries: systematic review.

October 5, 2022

Patient safety issues from information overload in electronic medical records.

September 14, 2022

Exploring the impact of employee engagement and patient safety.

September 14, 2022

A state-of-the-art review of speaking up in healthcare.

August 24, 2022

Defining and studying errors in surgical care: a systematic review.

August 17, 2022

Patient and family involvement in serious incident investigations from the perspectives of key stakeholders: a review of the qualitative evidence.

August 17, 2022

The effectiveness of improving healthcare teams' human factor skills using simulation-based training: a systematic review.

August 3, 2022

Mandating limits on workload, duty, and speed in radiology.

July 6, 2022

Instruments for measuring patient safety competencies in nursing: a scoping review.

June 15, 2022

Does standardisation improve post-operative anaesthesia handoffs? Meta-analyses on provider, patient, organisational, and handoff outcomes.

June 1, 2022

See More About The Topic

Researchers

Quality and Safety Professionals

Latent Errors

Root Cause Analysis

Root cause analysis using the prevention and recovery information system for monitoring and analysis method in healthcare facilities: a systematic literature review.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Root cause analysis using the prevention and recovery information system for monitoring and analysis method in healthcare facilities: a systematic literature review.

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