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Tampa, FL: International Society for Pharmaceutical Engineering; June 2013.
This worldwide survey determined root causes and underlying issues contributing to drug shortages and provides recommendations for industry and regulators to drive improvement.
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 Jul 25; [Epub ahead of print].
Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons learned.
Neily J, Silla ES, Sum-Ping SJT, et al. Anesth Analg. 2017 Jul 1; [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.
Adverse Health Events in Minnesota: 13th Annual Public Report.
St. Paul, MN: Minnesota Department of Health; February 2017.
Management of a patient with a latex allergy.
Minami CA, Barnard C, Bilimoria KY. JAMA. 2017;317:309-310.
Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?
Kellogg KM, Hettinger Z, Shah M, et al. BMJ Qual Saf. 2017;26:381-387.
Errors and Near Misses: What Health Care Could Learn From Aviation
Carl Macrae, PhD
In Conversation With... James P. Bagian, MD, PE
How to perform a root cause analysis for workup and future prevention of medical errors: a review.
Charles R, Hood B, Derosier JM, et al. Patient Saf Surg. 2016;10:20.
The problem with the '5 whys.'
Card AJ. BMJ Qual Saf. 2017;26:671-677.
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.
van Galen LS, Struik PW, Driesen BEJM, et al. PLoS One. 2016;11:e0161393.
The problem with root cause analysis.
Peerally MF, Carr S, Waring J, Dixon-Woods M. BMJ Qual Saf. 2017;26:417-422.
Unit-based incident reporting and root cause analysis: variation at three hospital unit types.
Wagner C, Merten H, Zwaan L, Lubberding S, Timmermans D, Smits M. BMJ Open. 2016;6:e011277.
A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change.
Clifford SP, Mick PB, Derhake BM. J Investig Med High Impact Case Rep. 2016;4:2324709616647746.
A new frontier in healthcare risk management: working to reduce avoidable patient suffering.
Card AJ, Klein VR. J Healthc Risk Manag. 2016;35:31-37.
Medical Device Use Error: Root Cause Analysis.
Wiklund M, Dwyer A, Davis E. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498705790.
Root Cause Analysis Playbook.
Chicago, IL: American Society for Healthcare Risk Management; 2015.
"SWARMing" to improve patient care: a novel approach to root cause analysis.
Li J, Boulanger B, Norton J, et al. Jt Comm J Qual Patient Saf. 2015;41:494-501.
Development of "SWARM" as a model for high reliability, rapid problem solving, and institutional learning.
Williams EA, Nikolai DA, Ladwig L, Miller C, Fredeboelling E. Jt Comm J Qual Patient Saf. 2015;41:508-513.
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.
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