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Rogith D, Iyengar SM, Singh H. Jt Comm J Qual Patient Saf. 2017;43:598-605.
Rogith D ; Iyengar SM ; Singh H.Using fault trees to advance understanding of diagnostic errors. Jt Comm J Qual Patient Saf. 2017; 43: 598-605
In-depth investigation of complicated processes can uncover underlying weaknesses that contribute to failure. This commentary describes how a project utilized fault-tree analysis as a method to examine elements that lead to diagnostic error.
Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences.
Stahel PF, Sabel AL, Victoroff MS, et al. Arch Surg. 2010;145:978-984.
Application of root cause analysis on malpractice claim files related to diagnostic failures.
van Noord I, Eikens MP, Hamersma AM, de Bruijne MC. Qual Saf Health Care 2010;19:e21.
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.
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.
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
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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