The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
Anderson JE, Watt AJ. Int J Qual Health Care. 2020;32:196-203.
Using a Safety-II framework, the authors used a mixed-methods approach to retrospectively analyze root cause analysis (RCA) reports of ‘never events’ occurring in the United Kingdom to characterize proposed actions, insights and recommendations to prevent future events. The analysis found that proposed actions were generally of low-to-moderate effectiveness, and that despite identifying systems challenges and weaknesses, many reports did not include proposed actions to mitigate or remove risks. The authors conclude that applying concepts from resilient healthcare can identify vulnerabilities and opportunities for strengthening the RCA system and improving the quality of RCA reports.
Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Learn more information here.