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Audiovisual > Meeting/Conference Proceedings
2005 Annual Patient Safety and Health Information Technology Conference: Making the Health Care System Safer through Implementation and Innovation.
Agency for Healthcare Research and Quality. June 6-10, 2005.
The Agency for Healthcare Research and Quality (AHRQ) hosted the 2005 Annual Patient Safety and Health Information Technology Conference. Transcripts and slide presentations are available from the five-day event.
Journal Article > Study
Mills PD, DeRosier JM, Ballot BA, Shepherd M, Bagian JP. Jt Comm J Qual Patient Saf. 2008;34:482-488.
The Department of Veterans Affairs has pioneered the use of root cause analysis to identify systems causes of adverse events. This study reports on the use of this technique to analyze inpatient suicide attempts at VA hospitals. Suicide attempts, the majority of which occur on inpatient psychiatric units, are considered a health care never event. Review of root cause analysis reports over a 7-year period identified several methods of self-harm and factors that facilitated suicide attempts. A prior study reported on preventive mechanisms that have been implemented at VA hospitals to reduce the risk of inpatient suicide attempts.