Impact of an Original Methodological Tool on the Identification of Corrective and Preventive Actions After Root Cause Analysis of Adverse Events in Health Care Facilities

2017 ◽  
Vol Publish Ahead of Print ◽  
Author(s):  
Anthony Vacher ◽  
Sana El Mhamdi ◽  
Alain d'Hollander ◽  
Marion Izotte ◽  
Yves Auroy ◽  
...  
Keyword(s):  
Health Care ◽  
Adverse Events ◽  
Root Cause Analysis ◽  
Health Care Facilities ◽  
Cause Analysis ◽  
Root Cause ◽  
Preventive Actions ◽  
Care Facilities ◽  
Methodological Tool

scholarly journals Root cause analysis applied to the investigation of serious untoward incidents in mental health services

2004 ◽  
Vol 28 (3) ◽  
pp. 75-77 ◽  
Author(s):  
L. A. Neal ◽  
D. Watson ◽  
T. Hicks ◽  
M. Porter ◽  
D. Hill
Keyword(s):  
Mental Health ◽  
Mental Health Services ◽  
Health Services ◽  
Adverse Events ◽  
Root Cause Analysis ◽  
Serious Adverse Events ◽  
Cause Analysis ◽  
Root Cause ◽  
Department Of Health ◽  
Investigative Process

The Department of Health publication Building a Safer NHS for Patients sets out the Government's plans for promoting patient safety (Department of Health, 2001). This follows growing international recognition that health services around the world have underestimated the scale of unintended harm or injury experienced by patients as a result of medical error and adverse events occurring in health care settings. These plans include a commitment to replace the procedures set out in the Department of Health circular HSG(94)27. This guidance details the methods for investigating every homicide (and some suicides) by patients in current or recent contact with specialist mental health services. Part of the process to modernise HSG(94)27 includes a plan to build expertise within the National Health Service (NHS) in the technique of root cause analysis. This investigative process was developed in industry to identify causal or systems factors in serious adverse events.

scholarly journals Root cause analysis – what do we know?

2021 ◽  
Vol 95 (1/2) ◽  
pp. 87-93 ◽  
Author(s):  
Wendy Groot
Keyword(s):  
Adverse Events ◽  
Audit Quality ◽  
Opportunity To Learn ◽  
Root Cause Analysis ◽  
Policy Makers ◽  
Cause Analysis ◽  
Root Cause ◽  
Audit Firms ◽  
The Future ◽  
Blame Culture

Root cause analysis (RCA) provides audit firms, regulators, policy makers and practitioners the opportunity to learn from past adverse events and prevent them from reoccurring in the future, leading to better audit quality. Recently approved regulations (ISQM1) make RCA mandatory for certain adverse events, making it essential to learn how to properly conduct an RCA. Building on the findings and recommendations from the RCA literature from other industries where RCA practice is more established such as the aviation and healthcare industries, audit firms can implement an adequate and effective RCA process. Based on the RCA literature, I argue that audit firms would benefit from a systems-based approach and establishing a no-blame culture.

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