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Joint Commission Resources Quality and Safety Network. August 23, 2018; 2:00–3:00 PM (Eastern).
Sentinel events present learning opportunities for hospitals to reduce risks for similar problems. This webinar will discuss the sentinel event policy, outline root cause analysis activities required to examine such events, and highlight alternative methods for reporting incidents.
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.
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.
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.
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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