Mass School Shootings in the United States: A Novel Root Cause Analysis Using Lay Press Reports

2019 ◽  
Vol 58 (13) ◽  
pp. 1423-1428 ◽  
Author(s):  
Chris A. Rees ◽  
Lois K. Lee ◽  
Eric W. Fleegler ◽  
Rebekah Mannix
Keyword(s):  
United States ◽  
Environmental Factors ◽  
Root Cause Analysis ◽  
The United States ◽  
School Shootings ◽  
Contributing Factors ◽  
Mass Shootings ◽  
Cause Analysis ◽  
Factors Associated ◽  
Root Cause

School shootings comprise a small proportion of childhood deaths from firearms; however, these shootings receive a disproportionately large share of media attention. We conducted a root cause analysis of 2 recent school shootings in the United States using lay press reports. We reviewed 1760 and analyzed 282 articles from the 10 most trusted news sources. We identified 356 factors associated with the school shootings. Policy-level factors, including a paucity of adequate legislation controlling firearm purchase and ownership, were the most common contributing factors to school shootings. Mental illness was a commonly cited person-level factor, and access to firearms in the home and availability of large-capacity firearms were commonly cited environmental factors. Novel approaches, including root cause analyses using lay media, can identify factors contributing to mass shootings. The policy, person, and environmental factors associated with these school shootings should be addressed as part of a multipronged effort to prevent future mass shootings.

Incident Investigation and Root Cause Analysis Method and Technology Review

2017 ◽  
Author(s):  
Guan Jianjun ◽  
Che Yinhui ◽  
Ma Lei
Keyword(s):  
Nuclear Power ◽  
Root Cause Analysis ◽  
The United States ◽  
Energy Agency ◽  
Cause Analysis ◽  
Root Cause ◽  
Incident Investigation ◽  
Analysis Methods ◽  
Methods And Techniques ◽  
Application Techniques

Incident investigation and root cause analysis (RCA) are widely used in nuclear power plant incident investigation and root cause confirmation. In this paper, based on the analysis literature reviews of root cause investigation of related incidents in IAEA (International Atomic Energy Agency), Europe and the United States, the analysis methods and techniques or tools of root causes in the world are studied, the incident investigation and analysis methods and techniques for root causes are analyzed and summarized. Through a comparison of various analysis methods and relevant application techniques and tools, differences between these root cause analysis techniques and tools are elaborated in terms of both concept and applicable application. In addition, application of RCA analysis methods and techniques is also briefed based on domestic RCA application practices.

Defining Mass Shootings

2021 ◽  
pp. 1-18
Keyword(s):  
United States ◽  
Developed Countries ◽  
The United States ◽  
School Shootings ◽  
Mass Shootings ◽  
Public Places ◽  
Post Offices ◽  
National Characteristics ◽  
Mass Shooting ◽  
History Of

This chapter interrogates public understandings of mass shootings. First of all, gun violence statistics for the United States are compared with those in other developed countries. The varying definitions and trends of mass shooting are shown to be problematic in trying to gain an accurate understanding of the phenomenon. Discussed is the history of mass shootings in the United States from “going postal” attacks occurring in post offices and workplace massacres through to school shootings and mass shootings in public places. Possible reasons why the United States has the highest number of mass shootings are deliberated. Hofstede's often-quoted cultural model is used to discuss two national characteristics: high levels of individualism and low power distance between social groups. Other factors highlighted relate to Harding, Fox, and Mehta's model about influencers of school shootings, as well as notions of extreme masculinity which are often expressed via misogynistic behavior.

scholarly journals Contributing factors to severe complications after liver resection: an aggregate root cause analysis in 105 consecutive patients.

2020 ◽  
Author(s):  
Kholoud Houssaini ◽  
Oumayma Lahnaoui ◽  
Amine Souadka ◽  
Mohamed-Anass Majbar ◽  
Abdelilah Ghannam ◽  
...  
Keyword(s):  
Liver Resection ◽  
Root Cause Analysis ◽  
Team Work ◽  
Contributing Factors ◽  
Cause Analysis ◽  
Resource Limitations ◽  
Root Cause ◽  
Contributory Factors ◽  
Safety Interventions ◽  
Individual Participant

Abstract Background: The aggregate root cause analysis (AggRCA) was designed to improve the understanding of system vulnerabilities contributing to patient harm, including surgical complications. It remains poorly used due to methodological complexity and resource limitations. This study aimed to identify the main patterns contributing to severe complications after liver resection using an AggRCA.Methods: This was a retrospective qualitative study aimed to identify the main patterns contributing to severe complications, defined as strictly higher than grade IIIa according to the Clavien-Dindo classification within the first 90 days after liver resection. All consecutive severe complications that occurred between January 1st, 2018 and December 31st, 2019 were identified from an electronic database and included in an AggRCA. This included a structured morbidity and mortality review (MMR) reporting tool based on 50 contributory factors adapted from 6 ALARM categories: “Patient”, “Tasks”, “Individual staff”, “Team”, “Work environment”, and “Management and Institutional context”. Data resulting from individual-participant root cause analysis (RCA) of single-cases were validated collectively then aggregated. The main patterns were suggested from the contributory factors reported in more than half of the cases.Results: In 105 consecutive liver resection cases, 15 patients (14.3%) developed severe postoperative complications, including 5 (4.8%) who died. AggRCA resulted in the identification of 36 contributory factors. Eight contributory factors were reported in more than half of the cases and were compiled in three entangled patterns: (1) Disrupted perioperative process, (2) Unplanned intraoperative change, (3) Ineffective communication.Conclusion: A pragmatic aggregated RCA process improved our understanding of system vulnerabilities based on the analysis of a limited number of events and a reasonable resource intensity. The identification of patterns contributing to severe complications lay the rationale of future contextualized safety interventions beyond the scope of liver resections.

scholarly journals Correction to: Contributing factors to severe complications after liver resection: an aggregate root cause analysis in 105 consecutive patients

2020 ◽  
Vol 14 (1) ◽  
Author(s):  
Kholoud Houssaini ◽  
Oumayma Lahnaoui ◽  
Amine Souadka ◽  
Mohammed Anass Majbar ◽  
Abdelilah Ghannam ◽  
...  
Keyword(s):  
Liver Resection ◽  
Root Cause Analysis ◽  
Contributing Factors ◽  
Cause Analysis ◽  
Root Cause

An amendment to this paper has been published and can be accessed via the original article.

scholarly journals Contributing factors to severe complications after liver resection: an aggregate root cause analysis in 105 consecutive patients

2020 ◽  
Vol 14 (1) ◽  
Author(s):  
Kholoud Houssaini ◽  
Oumayma Lahnaoui ◽  
Amine Souadka ◽  
Mohammed Anass Majbar ◽  
Abdelilah Ghannam ◽  
...  
Keyword(s):  
Liver Resection ◽  
Root Cause Analysis ◽  
Team Work ◽  
Contributing Factors ◽  
Cause Analysis ◽  
Resource Limitations ◽  
Root Cause ◽  
Contributory Factors ◽  
Safety Interventions ◽  
Individual Participant

Abstract Background The aggregate root cause analysis (AggRCA) was designed to improve the understanding of system vulnerabilities contributing to patient harm, including surgical complications. It remains poorly used due to methodological complexity and resource limitations. This study aimed to identify the main patterns contributing to severe complications after liver resection using an AggRCA. Methods This was a retrospective qualitative study aimed to identify the main patterns contributing to severe complications, defined as strictly higher than grade IIIa according to the Clavien-Dindo classification within the first 90 days after liver resection. All consecutive severe complications that occurred between January 1st, 2018 and December 31st, 2019 were identified from an electronic database and included in an AggRCA. This included a structured morbidity and mortality review (MMR) reporting tool based on 50 contributory factors adapted from 6 ALARM categories: “Patient”, “Tasks”, “Individual staff”, “Team”, “Work environment”, and “Management and Institutional context”. Data resulting from individual-participant root cause analysis (RCA) of single-cases were validated collectively then aggregated. The main patterns were suggested from the contributory factors reported in more than half of the cases. Results In 105 consecutive liver resection cases, 15 patients (14.3%) developed severe postoperative complications, including 5 (4.8%) who died. AggRCA resulted in the identification of 36 contributory factors. Eight contributory factors were reported in more than half of the cases and were compiled in three entangled patterns: (1) Disrupted perioperative process, (2) Unplanned intraoperative change, (3) Ineffective communication. Conclusion A pragmatic aggregated RCA process improved our understanding of system vulnerabilities based on the analysis of a limited number of events and a reasonable resource intensity. The identification of patterns contributing to severe complications lay the rationale of future contextualized safety interventions beyond the scope of liver resections.

Killers on Campus

2020 ◽  
pp. 156-174
Author(s):  
Michele W. Covington ◽  
Tracey L. Woodard
Keyword(s):  
Higher Education ◽  
United States ◽  
The United States ◽  
Colleges And Universities ◽  
School Shootings ◽  
Mass Shootings ◽  
Mass Public ◽  
The World ◽  
K 12 ◽  
Type Of School

More mass public shootings occur in the United States than anywhere else in the world, and these incidents occur in a variety of locations, including educational facilities. There is strong reason to separate elementary, middle, and high schools from institutes of higher education (such as colleges and universities) when studying mass school shootings. These incidents vary based on the type of school by the characteristics and motivations of the shooter as well as locational characteristics and appropriate prevention strategies. This chapter provides an overview of the differences between mass shootings at K-12 schools and those at IHEs. The authors also discuss the prevalence and characteristics of mass shootings at IHEs and introduce several prevention policies, along with relevant proposed and current legislation.

scholarly journals A qualitative content analysis of retained surgical items: learning from root cause analysis investigations

2020 ◽  
Vol 32 (3) ◽  
pp. 184-189
Author(s):  
Peter D Hibbert ◽  
Matthew J W Thomas ◽  
Anita Deakin ◽  
William B Runciman ◽  
Andrew Carson-Stevens ◽  
...  
Keyword(s):  
Content Analysis ◽  
Situational Awareness ◽  
Qualitative Content Analysis ◽  
Root Cause Analysis ◽  
Public Health Services ◽  
Contributing Factors ◽  
Cause Analysis ◽  
Root Cause ◽  
Great Root ◽  
The Impact

Abstract Objective To describe incidents of retained surgical items, including their characteristics and the circumstances in which they occur. Design A qualitative content analysis of root cause analysis investigation reports. Setting Public health services in Victoria, Australia, 2010–2015. Participants Incidents of retained surgical items as described by 31 root cause analysis investigation reports. Main Outcome Measure(s) The type of retained surgical item, the length of time between the item being retained and detected and qualitative descriptors of the contributing factors and the circumstances in which the retained surgical items occurred. Results Surgical packs, drain tubes and vascular devices comprised 68% (21/31) of the retained surgical items. Nearly one-quarter of the retained surgical items were detected either immediately in the post-operative period or on the day of the procedure (7/31). However, about one-sixth (5/31) were only detected after 6 months, with the longest period being 18 months. Contributing factors included complex or multistage surgery; the use of packs not specific to the purpose of the surgery; and design features of the surgical items. Conclusion Retained drains occurred in the post-operative phase where surgical counts are not applicable and clinician situational awareness may not be as great. Root cause analysis investigation reports can be a valuable means of characterizing infrequently occurring adverse events such as retained surgical items. They may detect incidents that are not detected by other data collections and can inform the design enhancements and development of technologies to reduce the impact of retained surgical items.

scholarly journals Analysis of the Clinical Education Situation framework: a tool for identifying the root cause of student failure in the United States

2019 ◽  
Vol 16 ◽  
pp. 11
Author(s):  
Katherine Myers ◽  
Kyle Covington
Keyword(s):  
Clinical Education ◽  
Root Cause Analysis ◽  
The United States ◽  
Primary Role ◽  
Cause Analysis ◽  
Academic Environments ◽  
Doctor Of Physical Therapy ◽  
Root Cause ◽  
Student Failure ◽  
Failure Event

Doctor of physical therapy preparation requires extensive time in precepted clinical education, which involves multiple stakeholders. Student outcomes in clinical education are impacted by many factors, and, in the case of failure, it can be challenging to determine which factors played a primary role in the poor result. Using existing root-cause analysis processes, the authors developed and implemented a framework designed to identify the causes of student failure in clinical education. This framework, when applied to a specific student failure event, can be used to identify the factors that contributed to the situation and to reveal opportunities for improvement in both the clinical and academic environments. A root-cause analysis framework can help to drive change at the programmatic level, and future studies should focus on the framework’s application to a variety of clinical and didactic settings.

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