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Search results for "Root Cause Analysis"
- Department of Health and Human Services (HHS)
- 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.
Journal Article > Study
Follow-up study of medication errors reported to the Vaccine Adverse Event Reporting System (VAERS).
Varricchio F, Reed J, and the VAERS Working Group. South Med J. 2006;99:486-489.
The investigators analyzed medication errors submitted to a national database to assess whether they were true errors, the reasons for these errors, and responses to the errors.
Rockville, MD: Agency for Healthcare Research and Quality; March 2007.
The Agency for Healthcare Research and Quality announces the 2007–2008 Patient Safety Improvement Corps (PSIC) program. States and organizations participating in the program will select staff members and its hospital partners to train in patient safety improvement. The applications period for this program cycle is now closed.
Tools, Methods, and Techniques for Improving Patient Safety: Patient Safety Improvement Corps Training DVD.
Rockville, MD: Agency for Healthcare Research and Quality; 2007.
This DVD provides training modules for health care professionals regarding systems-oriented, institutional improvements in patient safety.
Journal Article > Commentary
Battles JB, Dixon NM, Borotkanics RJ, Rabin-Fastmen B, Kaplan HS. Health Serv Res. 2006;41:1555-1575.
This commentary discusses the concept of "sensemaking" as a mechanism to better understand and mitigate the factors that contribute to medical errors. The authors begin by presenting a conceptual framework of sensemaking before discussing both retrospective (eg, root cause analysis) and prospective (eg, failure mode and effect analysis) tools that can be employed within organizations. After discussing probabilistic risk assessment, a case example is provided to illustrate the use of these tools and what is learned from their collective findings. The authors conclude that identifying risks to patient safety represents a critical step in prevention through the design of targeted interventions.
Journal Article > Study
Raab SS, Grzybicki DM, Zarbo RJ, Meier FA, Geyer SJ, Jensen C. Arch Pathol Lab Med. 2005;129:1246-1251.
This AHRQ-funded project describes the development of a national Web-based anatomic pathology database and how the information captured provided opportunities for intervention. Investigators first categorized the data into error types and frequency and also estimated the discrepancy rates with interpretation of recorded specimens. Subsequent root cause analyses identified system factors that contributed to the errors, and the authors share several quality improvement strategies implemented in response. While the study data derive only from self-reported institutional errors, the opportunity to expand the process to additional institutions may identify shared system deficiencies or specific error types that warrant greater attention. The process outlined resembles in many ways the efforts of reporting systems in general as a mechanism to learn and improve from past experiences with errors.