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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.
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.
Root Cause Analyses and Actions (RCA2).
Institute for Healthcare Improvement. January 24-April 4, 2018; 12:00-1:00 PM (Eastern).
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.
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.
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.
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.
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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