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Search results for "Root Cause Analysis"
- Root Cause Analysis
Legislation/Regulation > Organizational Policy/Guidelines
Washington, DC: Veterans Health Administration; March 4, 2011.
A handbook developed by the VA and the National Center for Patient Safety that provides guidance on how to limit opportunities that adversely impact patient safety and care. The strategies discussed incorporate the use of root cause analysis, a tool designed to understand and communicate safety-related issues.
Legislation/Regulation > Multi-use Website
The Joint Commission.
Since 1998, The Joint Commission has issued sentinel event alerts in response to unexpected incidents involving death or serious physical or psychological injury (or risk thereof). These events are identified as sentinel due to the gravity of the injury and the need for immediate investigation and response. The goal is often to determine the root causes involved and provide recommendations for future prevention. The Sentinel Event Alert Web site includes a complete library of previous sentinel event alerts, along with related statistics, podcasts, forms, tools, policy and procedures, and a frequently asked questions section reviewing selected recent topics.
Legislation/Regulation > Sentinel Event Alerts
The Joint Commission. Sentinel Event Alert. December 20, 2004;(33):1-2.
Patient-controlled analgesia (PCA) is a recognized method of controlling pain when administered by credentialed practitioners. However, serious adverse events can result when unauthorized family members, caregivers, or clinicians administer the analgesia for the patient "by proxy." The Joint Commission summarizes the experience of reported PCA incidents and makes recommendations to minimize them.
Oakbrook Terrace, IL: The Joint Commission.
This newsletter provides guidance to health care organizations for responding to commonly reported incidents. The Joint Commission issues these sentinel event alerts to review selected incidents, determine the root causes involved, and provide a summary of recommendations for future prevention.