U.S. Department of Health and Human Services
Agency for Healthcare Research and Quality: Advancing Excellence in Health Care
Sign up for a Free Account
Fassett WE. Am J Pharm Educ. 2011;75:164.
Fassett WE.Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills. Am J Pharm Educ. 2011; 75: 164
This commentary recommends that courses covering root cause analysis, failure mode and effects analysis (FMEA), and SBAR (situation, background, assessment, recommendation) be built into health care curriculum.
Random safety auditing, root cause analysis, failure mode and effects analysis.
Ursprung R, Gray J. Clin Perinatol. 2010;37:141-165.
Patient Safety Curriculum.
Ann Arbor, MI: National Center for Patient Safety.
Geometric probability distribution for modeling of error risk during prescription dispensing.
Carnahan BJ, Maghsoodloo S, Flynn EA, Barker KN. Am J Health Syst Pharm. 2006;63:1056-1061.
Follow-up study of medication errors reported to the Vaccine Adverse Event Reporting System (VAERS).
Varricchio F, Reed J, and the VAERS Working Group. South Med J. 2006;99:486-489.
Sentinel Events Update: Improving Root Cause Analyses and Actions to Prevent Harm.
Joint Commission Resources Quality and Safety Network. August 23, 2018; 2:00–3:00 PM (Eastern).
Physician burnout in the electronic health record era: are we ignoring the real cause?
Downing NL, Bates DW, Longhurst CA. Ann Intern Med. 2018;169:50-51.
Adverse Health Events in Minnesota: 14th Annual Public Report.
St. Paul, MN: Minnesota Department of Health; February 2018.
Oversedation of a patient with obstructive sleep apnea prior to imaging.
Blay E Jr, Barnard C, Bilimoria KY. JAMA. 2018;319:495-496.
Patient safety in complementary medicine through the application of clinical risk management in the public health system.
Rossi EG, Bellandi T, Picchi M, et al. Medicines (Basel). 2017;4:E93.
Perfecting Detection: Understanding the Source of Harm.
Child Health Patient Safety Organization. Washington, DC: Children's Hospital Association; 2017.
Impact of an original methodological tool on the identification of corrective and preventive actions after root cause analysis of adverse events in health care facilities: results of a randomized controlled trial.
Vacher A, El Mhamdi S, d'Hollander A, et al. J Patient Saf. 2017 Nov 8; [Epub ahead of print].
Root Cause Analysis in Health Care: Tools and Techniques. 6th Edition.
Oakbrook Terrace, IL: Joint Commission Resources; 2017. ISBN: 9781599409849.
Using fault trees to advance understanding of diagnostic errors.
Rogith D, Iyengar SM, Singh H. Jt Comm J Qual Patient Saf. 2017;43:598-605.
Implementation of a mock root cause analysis to provide simulated patient safety training.
Murphy M, Duff J, Whitney J, Canales B, Markham M, Close J. BMJ Open Quality. 2017;6:e000096.
Root cause analysis of ICU adverse events in the Veterans Health Administration.
Corwin GS, Mills PD, Shanawani H, Hemphill RR. Jt Comm J Qual Patient Saf. 2017;43:580–590.
Preventing blood transfusion failures: FMEA, an effective assessment method.
Najafpour Z, Hasoumi M, Behzadi F, Mohamadi E, Jafary M, Saeedi M. BMC Health Serv Res. 2017;17:453.
Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons learned.
Neily J, Silla ES, Sum-Ping SJT, et al. Anesth Analg. 2018;126:471-477.
Using prospective risk analysis tools to improve safety in pharmacy settings: a systematic review and critical appraisal.
Stojkovic T, Marinkovic V, Manser T. J Patient Saf. 2017 Jun 29; [Epub ahead of print].
Root Cause Analysis
Investigating the causes of adverse events.
Sanchez JA, Lobdell KW, Moffatt-Bruce SD, Fann JI. Ann Thorac Surg. 2017;103:1693-1699.
Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports.
Riblet N, Shiner B, Watts BV, Mills P, Rusch B, Hemphill RR. J Nerv Ment Dis. 2017;205:436-442.
Root cause analysis and actions for the prevention of medical errors: quality improvement and resident education.
Charles R, Hood B, DeRosier JM, et al. Orthopedics. 2017;40:e628-e635.
Root cause analysis of adverse events in an outpatient anticoagulation management consortium.
Graves CM, Haymart B, Kline-Rogers E, et al. Jt Comm J Qual Patient Saf. 2017;43:299-307.
Root-cause analysis: swatting at mosquitoes versus draining the swamp.
Trbovich P, Shojania KG. BMJ Qual Saf. 2017;26:350-353.
Patient Safety: Investigating and Reporting Serious Clinical Incidents.
Kelsey R. CRC Press: Boca Raton, FL; 2017. ISBN: 9781498781169.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
Agency for Healthcare Research and Quality
5600 Fishers Lane
Rockville, MD 20857
Telephone: (301) 427-1364