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Search results for "Root Cause Analysis"
- Web Resource
- Root Cause Analysis
St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
Washington, DC: United States Government Accountability Office; July 29, 2015. Publication GAO-15-643.
The National Center for Patient Safety (NCPS) has contributed to patient safety improvement initiatives in the Department of Veterans Affairs (VA) since its inception. This investigation explored VA medical centers' application of root cause analysis after adverse events and how findings from these analyses were used to make system-wide improvements. This report found that the number of root cause analyses performed has decreased and the NCPS has not yet sought to determine why, but factors such as use of other incident analysis methods may have contributed. The Government Accountability Office recommends that the VA assess reasons behind the decline in use of root cause analysis and the extent to which alternative strategies are being utilized.
Web Resource > Course Material/Curriculum
Ann Arbor, MI: National Center for Patient Safety.
This curriculum introduces basic patient safety concepts and provides materials to support students, instructors, and faculty educators.
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.
Web Resource > Multi-use Website
Department of Veterans Affairs (VA), PO Box 486, Ann Arbor, MI 48106-0486.
The NCPS represents a unified and cohesive patient safety effort. The program, which won the John Eisenberg Award in 2002, is unique in health care. It focuses on prevention rather than punishment by applying human factors analysis and the safety research of high-reliability organizations. This process is targeted at identifying and eliminating system vulnerabilities.
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.
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.
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.
US Government Accountability Office. Washington, DC: US Government Accountability Office; 2004. Publication GAO-05-83.
The Government Accountability Office studied patient safety programs at four Department of Veterans Affairs (VA) health facilities and recommends that the VA emphasize leadership action and open communication to support safety improvement.