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Search results for "Root Cause Analysis"
Journal Article > Study
Andersen HB, Siemsen IMD, Petersen LF, Nielsen J, Østergaard D. Cogn Technol Work. 2015;17:79-87.
Patient handoffs are a common source of adverse events, often due to communication failures, particularly for tests that are pending at discharge. This research group used incident reports, interviews, and root cause analysis reports to create and validate a taxonomy for classifying adverse events related to patient handovers.
Case study: sustaining a culture of safety in the U.S. Department of Veterans Affairs Health Care System.
Chase D, McCarthy D. Quality Matters. April/May 2010.