The PSNet Collection: All Content
Search All Content
Institute for Healthcare Improvement. Mar 14 - May 16, 2023.
Collaborative for Accountability and Improvement. January 26, 2023, 2:00-3:00 PM (eastern).
Portland, OR: Oregon Patient Safety Commission; 2022.
This primer provides a broad overview of three widely used tools for investigating and responding to patient safety events and near misses. Tools covered in this primer are incident reporting systems, Root Cause Analysis (RCA), and Failure Modes and Effects Analysis (FMEA). These tools have been used in high-risk industries and occupations such as aviation, manufacturing, nuclear power, and the military and have been adapted for use in enhancing patient safety in healthcare settings over the past two decades.
This case involves a 2-year-old girl with acute myelogenous leukemia and thrombocytopenia (platelet count 26,000 per microliter) who underwent implantation of a central venous catheter with a subcutaneous port. The anesthetist asked the surgeon to order a platelet transfusion to increase the child’s platelet count to above 50,000 per microliter. In the post-anesthesia care unit, the patient’s arterial blood pressure started fluctuating and she developed cardiac arrest.
Washington, DC: Veterans Affairs Office of Inspector General; August 26, 2021. Report No. 21-01502-240.