This report analyzed a patient suicide at an emergency department and determined factors in the delay of care that contributed to patient harm. This report shares recommendations to address leadership failures and other deficiencies including poor screening and patient monitoring. Post-event gaps identified include poor root cause analysis, disclosure, and reporting activities.

Root cause analysis (RCA) is one tool commonly used to identify factors contributing to adverse events. Using RCA data from the Veterans Health Administration (VHA), this study characterized adverse events occurring during urologic procedures. The most common causes of adverse events were improperly functioning equipment (e.g., broken scopes or smoking light cords), wrong site surgeries, and retained surgical items.

Root cause analysis (RCA) is a widely recognized retrospective strategy for learning from failure that is challenging to implement. This series of webinars will feature an innovative approach to RCA that expands on the concept to facilitate its use in incident investigations. Instructors for the series will include Dr. Terry Fairbanks and Dr. Tejal K. Gandhi.

Root cause analysis (RCA) is a recognized approach to examining failures by identifying causal factors to define improvement effort. This session discussed challenges to the effective use of RCA results and examine an approach to present them that supports effective improvement action.

Patient falls are common sentinel events. The latest revision of this toolkit shares insights on applying the tenets of root cause analysis to falls investigations.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2021 report summarizes information about 508 adverse events that were reported, representing a significant increase in the year covered. Earlier reports document a fairly consistent count of adverse events. The rise reflected here is likely due to demands on staffing and care processes associated with COVID-19. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.