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Journal Article > Commentary
Soncrant CM, Warner LJ, Neily J, et al. AORN J. 2018;108:386-397.
Root cause analysis has been widely promoted as a failure analysis tool for use in a variety of settings. This quality improvement project applied the method to patient falls in Veterans Health Administration operating rooms and developed recommendations to guide improvement. Areas of focus included team communication, restraint use, and staff education. An Annual Perspective provides insights regarding how to enhance root cause analysis to help investigate incidents and improve care.
Journal Article > Study
Surgical programs in the Veterans Health Administration maintain briefing and debriefing following medical team training.
West P, Neily J, Warner L, et al. Jt Comm J Qual Patient Saf. 2014;40:235-239.
This study surveyed nurse managers to evaluate the implementation of pre-surgical briefings and post-surgical debriefings recommended by the World Health Organization's Safe Surgery program. Researchers found that practices were variably sustained and team training appeared to augment implementation.
Health Care Inspection. Washington, DC: VA Office of Inspector General; April 10, 2006. Report No. 06-01642-126.
This report shares the results of an inspection into two mistakes at a Veterans Affairs (VA) health facility involving appropriate sterilization of implantable medical devices.