Anesthesia Handoff: A Root Cause Analysis Based on a Near-Miss Scenario

2012 ◽  
Vol 5 (2) ◽  
pp. 132-136 ◽  
Author(s):  
Eileen Y. Evanina ◽  
Nicole L. Monceaux
Keyword(s):  
Patient Safety ◽  
Patient Information ◽  
Root Cause Analysis ◽  
Joint Commission ◽  
Near Miss ◽  
Hospital Organization ◽  
Cause Analysis ◽  
Root Cause ◽  
Anesthesia Providers ◽  
Effective Transfer

The Joint Commission on Accreditation of Hospital Organization (JCAHO) has handoff requirements to create the safe and effective transfer of patient information between providers. Multiple studies have investigated standardized nurse-to-nurse handoffs and nurse-to-physician handoffs. However, very few studies have examined handoff communication between anesthesia providers. A near-miss scenario during a sitting craniotomy procedure is reviewed, and a root cause analysis conducted to demonstrate the importance of communication and how a standardized anesthesia handoff tool can facilitate patient safety.

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.

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