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Search results for "Medical Complications"
Journal Article > Study
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.
This analysis of the Veterans Health Administration root cause analysis database identified adverse events that occurred during rehabilitation services, such as physical therapy, occupational therapy, or speech and language therapy. Rehabilitation-related adverse events were extremely rare. The most common incidents were falls and delayed response to clinical deterioration.
Journal Article > Commentary
Cerniglia-Lowensen J. J Radiol Nurs. 2015;34:4-7.
Root cause analysis has been promoted by The Joint Commission and other organizations as a failure analysis tool, though problems with its usefulness remain due to issues with implementation and sufficient follow-up. This commentary provides an overview of the process and uses a case study to illustrate its value as a safety improvement strategy.
Perspectives on Safety > Perspective
with commentary by Ashish K. Jha, MD, MPH, The Transformation of Patient Safety at the VA, September 2006
Five years after the landmark Crossing the Quality Chasm report by the Institute of Medicine (IOM), the quality and safety of health care in the United States remains far from ideal.(1) It is easy to feel pessimistic. Can health care organizations really...