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Search results for "Root Cause Analysis"
- Policy Makers
- Root Cause Analysis
Tampa, FL: International Society for Pharmaceutical Engineering; June 2013.
Journal Article > Study
van Noord I, Eikens MP, Hamersma AM, de Bruijne MC. Qual Saf Health Care 2010;19:e21.
Perspectives on Safety > Perspective
Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
with commentary by James B. Conway; Saul N. Weingart, MD, PhD, Errors in the Media and Organizational Change, May 2005
A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...
Washington, DC: National Quality Forum; 2011. ISBN: 9780982842188.
The National Quality Forum originally defined 27 health care "never events"—patient safety events that pose serious harm to patients, but should be considered preventable—in 2002. The 2011 update now consists of 29 events, organized into surgical events (e.g., wrong-site surgery), device events (e.g., air embolism), care management events (e.g., death or disability due to medication errors), patient protection events (e.g., patient suicide), environmental events (e.g., fires), radiologic events, and criminal events. One notable addition to the original list is that serious harm associated with failure to properly follow up on test results is now considered a never event. Since the development and dissemination of this list, many states have mandated that health care facilities report all instances of these events. When such an event occurs, many institutions mandate performance of a root cause analysis.
Web Resource > Multi-use Website
Burgemeester van Leeuwenlaan 93-3, 1064KP, Amsterdam, The Netherlands.
This Web site provides patient safety information for developing countries.
Perspectives on Safety > Interview
Accreditation and Regulation, April 2009
Mark R. Chassin, MD, MPP, MPH, is president of The Joint Commission, the preeminent standard setting and accrediting organization in health care in the United States and, increasingly, the world. Over the course of his notable career, Dr. Chassin, an emergency medicine physician, has held a variety of key positions, including New York State Health Commissioner and chair of the department of health policy at Mt. Sinai. He has published several seminal papers and was a member of the team that authored the IOM report, "To Err Is Human." We asked him to speak with us about his role at The Joint Commission, as well as future directions for the organization.
Perspectives on Safety > Interview
State Error Reporting Systems, June 2007
Diane Rydrych, MA, is Assistant Director of the Division of Health Policy at the Minnesota Department of Health, where she oversees their successful and influential adverse health events reporting system. We asked her to speak with us about the Minnesota initiative and some of the broader lessons for state error reporting systems.
Gulliver D. Sarasota Herald Tribune. November 7, 2006:BS1.
This article reports on the death of a restrained patient and outlines the factors affecting the subsequent reporting of the event.
Special or Theme Issue
Health Serv Res. 2006;41:1535-1720.
Journal Article > Commentary
Pauker SG, Zane EM, Salem DN. JAMA. 2005;294:2906-2908.
This editorial builds on the discussion from a study suggesting that overall improvement in the adoption and implementation of patient safety systems is slow. The authors offer a series of explanations for these delays in important improvements and apply the concept called the "theory of constraints." This theory asks the question of what should change, to what should it change, and how should change occur. Responses are framed with discussion of six thought processes that must occur at an organization for change to become possible. These include agreement that a problem exists, agreement that a proposed solution actually solves the problem, and identifying obstacles and how they can be overcome. The authors argue that sustained change occurs only when these root causes receive appropriate exploration and direct action in fostering improved safety systems.
Journal Article > Study
Longo DR, Hewett JE, Ge B, Schubert S. JAMA. 2005;294:2858-2865.
To grade progress since release of the landmark Institute of Medicine (IOM) report, this AHRQ-funded study examined the status and evolution of patient safety systems through a survey of acute care hospitals in Missouri and Utah. Investigators characterized their assessment based on variables that included presence of computerized physician order entry systems, computerized test results, evaluation of adverse drug events, specific patient safety policies, use of data in patient safety programs, drug administration and safety procedures, error reporting processes, prevention policies, and root cause analyses. More than 100 hospitals completed the survey in 2002 and again in 2004. Findings demonstrated only modest improvements in certain areas with variability noted in others. For instance, surgical areas and medication processes seemed to embrace the greatest level of patient safety systems. However, the authors point out that the overall findings fall short of the IOM recommendations and necessitate a more intensive agenda for accelerated improvements. An accompanying editorial (link below) provides an overview of the factors and challenges involved in promoting change to improve patient safety.
Gaul GM. The Washington Post. July 29, 2005:A06.
This article presents the newly passed Patient Safety and Quality Improvement Act of 2005 in comparison to mandatory, state-based reporting initiatives.