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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
Lee A, Mills PD, Watts BV. Gen Hosp Psychiatry. 2012;34:304-311.
This study reviewed 75 root cause analyses from the Veterans Health Administration system to highlight common activities during falls and frequent contributing factors. Getting up from a bed or chair was the most common activity, whereas environmental hazards and poor communication of fall risk were the most common contributing factors.