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Sanchez JA, Lobdell KW, Moffatt-Bruce SD, Fann JI. Ann Thorac Surg. 2017;103:1693-1699.
Sanchez JA ; Lobdell KW ; Moffatt-Bruce SD; et al. Investigating the causes of adverse events. Ann Thorac Surg. 2017; 103: 1693-1699
Incident analysis enables learning from errors. This commentary explores elements of successful event investigation such as determining causal factors, describes root cause analysis, and reviews biases that can influence such investigations.
Root Cause Analysis
Root cause analysis of reported patient falls in ORs in the Veterans Health Administration.
Soncrant CM, Warner LJ, Neily J, et al. AORN J. 2018;108:386-397.
Experience feedback committees: a way of implementing a root cause analysis practice in hospital medical departments.
François P, Lecoanet A, Caporossi A, Dols AM, Seigneurin A, Boussat B. PLoS One. 2018;13:e0201067.
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.
An analysis of adverse events in the rehabilitation department: using the Veterans Affairs root cause analysis system.
Hagley GW, Mills PD, Shiner B, Hemphill RR. Phys Ther. 2018;98:223-230.
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.
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.
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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