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- Communication Improvement 3
- Culture of Safety 2
- Error Reporting and Analysis
- Human Factors Engineering 2
- Legal and Policy Approaches 3
- Logistical Approaches 1
- Quality Improvement Strategies 1
- Device-related Complications 2
- Drug shortages 1
- Identification Errors 1
- Medical Complications 2
- Medication Safety 4
- Surgical Complications 2
Search results for "Book/Report"
- Root Cause Analysis
St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
Child Health Patient Safety Organization. Washington, DC: Children's Hospital Association; 2017.
Oakbrook Terrace, IL: Joint Commission Resources; 2017. ISBN: 9781599409849.
Root cause analysis has been widely adopted as a strategy to investigate events, despite questions regarding its effectiveness in health care. This book provides information about updated approaches to root cause analysis, including how this strategy enables design of proactive and reactive improvements.
Kelsey R. CRC Press: Boca Raton, FL; 2017. ISBN: 9781498781169.
Preventing Patient Falls: A Systematic Approach From the Joint Commission Center for Transforming Healthcare Project.
Chicago, IL: Health Research & Educational Trust; October 2016.
Falls are a common hazard among both hospitalized and ambulatory patients. This report summarizes the results of a collaborative to identify and address the root causes of falls in hospitals and provides case studies from the participating organizations to illustrate their experiences during the initiative.
Wiklund M, Dwyer A, Davis E. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498705790.
Applying human factors engineering to examine mistakes associated with medical device use can lead to valuable learning opportunities. This publication discusses equipment use errors and provides information about utilizing root cause analysis (RCA) to identify weaknesses in device design that enable those mistakes. The book includes examples of RCAs to illustrate how the method can uncover flaws that contribute to error in various situations.
Chicago, IL: American Society for Healthcare Risk Management; 2015.
Risk management has recently focused on organization-wide improvement in patient safety. This publication discusses root cause analysis methods that risk managers can use to identify problems and inform design of safety initiatives. Highlighted strategies include failure mode identification and intervention planning.
Washington, DC: United States Government Accountability Office; July 29, 2015. Publication GAO-15-643.
The National Center for Patient Safety (NCPS) has contributed to patient safety improvement initiatives in the Department of Veterans Affairs (VA) since its inception. This investigation explored VA medical centers' application of root cause analysis after adverse events and how findings from these analyses were used to make system-wide improvements. This report found that the number of root cause analyses performed has decreased and the NCPS has not yet sought to determine why, but factors such as use of other incident analysis methods may have contributed. The Government Accountability Office recommends that the VA assess reasons behind the decline in use of root cause analysis and the extent to which alternative strategies are being utilized.
Boston, MA: National Patient Safety Foundation; 2015.
The National Patient Safety Foundation issued these guidelines for improving root cause analyses (RCAs) in health care organizations. RCAs are mandated by The Joint Commission following sentinel events and many states require them after reports of serious events. A panel of experts and stakeholders created these guidelines, which emphasize the importance of actions taken in response to RCA reviews to prevent future harms. They have proposed renaming the process root cause analysis and action (RCA²) to ensure that efforts will result in the implementation of sustainable systems-based improvements. The document provides strategies for applying efficient and effective RCAs, and it includes tools for evaluating RCA reviews. A prior AHRQ WebM&M perspective examined the application of RCAs for patient safety.
Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming Healthcare Project.
Chicago, IL: American Hospital Association, Health Research and Educational Trust, and Joint Commission Center for Transforming Healthcare; 2014.
Wrong-site surgery is a never event, but still occurs at alarming rates. This report discusses risks related to wrong-site surgery, along with their root causes, and describes initiatives associated with a Joint Commission Center for Transforming Healthcare project. The authors highlight improvements in scheduling surgeries, preoperative processes, operating room preparations, and organizational culture that substantially reduced wrong-site surgeries in the eight hospitals participating in the program. A prior AHRQ WebM&M commentary by Dr. Charles Vincent discussed a case of a wrong-site procedure.
Tampa, FL: International Society for Pharmaceutical Engineering; June 2013.
Horsham, PA: Institute for Safe Medication Practices; 2013.
Washington, DC: National Quality Forum; 2011. ISBN: 9780982842188.
The National Quality Forum originally defined 27 health care "never events"—patient safety events that pose serious harm to patients, but should be considered preventable—in 2002. The 2011 update now consists of 29 events, organized into surgical events (e.g., wrong-site surgery), device events (e.g., air embolism), care management events (e.g., death or disability due to medication errors), patient protection events (e.g., patient suicide), environmental events (e.g., fires), radiologic events, and criminal events. One notable addition to the original list is that serious harm associated with failure to properly follow up on test results is now considered a never event. Since the development and dissemination of this list, many states have mandated that health care facilities report all instances of these events. When such an event occurs, many institutions mandate performance of a root cause analysis.
Omaha, NE: Jones K, Skinner A, Cochran G, Knudson A, Beattie S, Mueller K; for University of Nebraska Medical Center and Nebraska Center for Rural Research; 2007.
Toronto, ON, Canada: Institute for Safe Medication Practices Canada. April 30, 2007.
McKee J, ed. Oakbrook Terrace, IL: Joint Commission Resources; 2005. ISBN: 0866889116.
This book provides information on implementing the Joint Commission on Accreditation of Healthcare Organization's (JCAHO) Sentinel Event Policy in all health care settings. The text includes a sample sentinel event root cause analysis form and a glossary.
Oakbrook Terrace, IL; Joint Commission on Accreditation of Healthcare Organizations; 2006. ISBN: 0866889892.
This book provides a complete overview of the Joint Commission on Accreditation of Healthcare Organization's National Patient Safety Goals and how to apply them in various settings. In addition, it discusses the role that patient safety plays in the accreditation process.
US Government Accountability Office. Washington, DC: US Government Accountability Office; 2004. Publication GAO-05-83.
The Government Accountability Office studied patient safety programs at four Department of Veterans Affairs (VA) health facilities and recommends that the VA emphasize leadership action and open communication to support safety improvement.
Corbett C, Clapper C, Johnson KM, Sheff RA. Marblehead, Mass: HCPro, Inc.; 2004.
A "how-to" book for organizations that have already implemented a root cause analysis (RCA) process in response to JCAHO's standards. The book provides opportunities to improve current processes and procedures.