Root Cause Analysis (RCA) for the Improvement of Healthcare Systems and Patient Safety

2021 ◽  
Author(s):  
David Allison ◽  
Harold Peters
Keyword(s):  
Patient Safety ◽  
Root Cause Analysis ◽  
Healthcare Systems ◽  
Cause Analysis ◽  
Root Cause

Improving Root Cause Analysis of Patient Safety Events in Radiology

Radiographics ◽  
2020 ◽  
Vol 40 (5) ◽  
pp. 1434-1440
Author(s):  
Ashley S. Rosier ◽  
Laura C. Tibor ◽  
Mara A. Turner ◽  
Carrie J. Phillips ◽  
A. Nicholas Kurup
Keyword(s):  
Patient Safety ◽  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause

scholarly journals Severe Ventral Erosion of Penis Caused by Indwelling Urethral Catheter and Inflation of Foley Balloon in Urethra—Need to Create List of “Never Events in Spinal Cord Injury” in order to Prevent These Complications from Happening in Paraplegic and Tetraplegic Patients

2010 ◽  
Vol 2010 ◽  
pp. 1-5 ◽  
Author(s):  
Subramanian Vaidyanathan ◽  
Bakul M. Soni ◽  
Peter L. Hughes ◽  
Gurpreet Singh ◽  
Tun Oo
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Patient Safety ◽  
Root Cause Analysis ◽  
Urethral Catheter ◽  
Learning System ◽  
Cause Analysis ◽  
Root Cause ◽  
Cord Injury ◽  
Never Events

Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. We propose that a list of “Never Events” is created for spinal cord injury patients in order to improve the quality of care. To begin with, following two preventable complications related to management of neuropathic bladder may be included in this list of “Never Events.” (i) Severe ventral erosion of glans penis and penile shaft caused by indwelling urethral catheter; (ii) incorrect placement of a Foley catheter leading to inflation of Foley balloon in urethra. If a Never Event occurs, health professionals should report the incident through hospital risk management system to National Patient Safety Agency's Reporting and Learning System, communicate with the patient, family, and their carer as soon as possible about the incident, undertake a comprehensive root cause analysis of what went wrong, how, and why, and implement the changes that have been identified and agreed following the root cause analysis.

Anatomic Pathology Databases and Patient Safety

2005 ◽  
Vol 129 (10) ◽  
pp. 1246-1251 ◽  
Author(s):  
Stephen S. Raab ◽  
Dana M. Grzybicki ◽  
Richard J. Zarbo ◽  
Frederick A. Meier ◽  
Stanley J. Geyer ◽  
...  
Keyword(s):  
Patient Safety ◽  
Root Cause Analysis ◽  
Error Reduction ◽  
Design Quality ◽  
Cause Analysis ◽  
Root Cause ◽  
Anatomic Pathology ◽  
Sources Of Error ◽  
Error Frequency ◽  
Project Site

Abstract Context.—The utility of anatomic pathology discrepancies has not been rigorously studied. Objective.—To outline how databases may be used to study anatomic pathology patient safety. Design.—The Agency for Healthcare Research and Quality funded the creation of a national anatomic pathology errors database to establish benchmarks for error frequency. The database is used to track more frequent errors and errors that result in more serious harm, in order to design quality improvement interventions intended to reduce these types of errors. In the first year of funding, 4 institutions (University of Pittsburgh, Henry Ford Hospital, University of Iowa, and Western Pennsylvania Hospital) reported cytologic-histologic correlation error data after standardizing correlation methods. Root cause analysis was performed to determine sources of error, and error reduction plans were implemented. Participants.—Four institutions self-reported anatomic pathology error data. Main Outcome Measures.—Frequency of cytologic-histologic correlation error, case type, cause of error (sampling or interpretation), and effect of error on patient outcome (ie, no harm, near miss, and harm). Results.—The institutional gynecologic cytologic-histologic correlation error frequency ranged from 0.17% to 0.63%, using the denominator of all Papanicolaou tests. Based on the nongynecologic cytologic-histologic correlation data, the specimen sites with the highest discrepancy frequency (by project site) were lung (ranging from 16.5% to 62.3% of all errors) and urinary bladder (ranging from 4.4% to 25.0%). Most errors detected by the gynecologic cytologic-histologic correlation process were no-harm events (ranging from 10.7% to 43.2% by project site). Root cause analysis identified sources of error on both the clinical and pathology sides of the process, and error intervention programs are currently being implemented to improve patient safety. Conclusions.—A multi-institutional anatomic pathology error database may be used to benchmark practices and target specific high-frequency errors or errors with high clinical impact. These error reduction programs have national import.

Effectiveness of systems changes suggested by simulation of adverse surgical outcomes

2015 ◽  
Vol 1 (3) ◽  
pp. 83-86 ◽  
Author(s):  
Meghan E Garstka ◽  
Douglas P Slakey ◽  
Christopher A Martin ◽  
Eric R Simms ◽  
James R Korndorffer
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
Adverse Events ◽  
Surgical Outcomes ◽  
Improve Patient Safety ◽  
Healthcare Systems ◽  
Adverse Outcomes ◽  
Cause Analysis ◽  
Root Cause ◽  
Improve Patient

BackgroundSimulation of adverse outcomes (SAO) has been described as a technique to improve effectiveness of root cause analysis (RCA) in healthcare. We hypothesise that SAO can effectively identify unsuspected root causes amenable to systems changes.MethodsSystems changes were developed and tested for effectiveness in a modified simulation, which was performed eight times, recorded and analysed.ResultsIn seven of eight simulations, systems changes were effectively utilised by participants, who contacted anaesthesia using the number list and telephone provided to express concern. In six of seven simulations where anaesthesia was contacted, they provided care that avoided the adverse event. In two simulations, the adverse event transpired despite implemented systems changes, but for different reasons than originally identified. In one case, appropriate personnel were contacted but did not provide the direction necessary to avoid the adverse event, and in one case, the telephone malfunctioned.ConclusionsSystems changes suggested by SAO can effectively correct deficiencies and help improve outcomes, although adverse events can occur despite implementation. Further study of systems concepts may provide suggestions for changes that function more reliably in complex healthcare systems. The information gathered from these simulations can be used to identify potential deficiencies, prevent future errors and improve patient safety.

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