scholarly journals Using Simulation Technology and The Root Cause Analysis Process to Assess Nurse’s Attitude toward Patient Safety

2017 ◽  
Vol 1 (2) ◽  
Author(s):  
Ruth Everett Thomas
Keyword(s):  
Patient Safety ◽  
Root Cause Analysis ◽  
Simulation Technology ◽  
Cause Analysis ◽  
Root Cause ◽  
Analysis Process

scholarly journals Early Engagement of Residents Into the Root Cause Analysis Process

2016 ◽  
Vol 8 (3) ◽  
pp. 459-460 ◽  
Author(s):  
Miriam Bar-on ◽  
Ross P. Berkeley
Keyword(s):  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause ◽  
Analysis Process

scholarly journals Employing a Root Cause Analysis Process to Improve Examination Quality

2019 ◽  
Vol 94 (1) ◽  
pp. 71-75 ◽  
Author(s):  
Sally A. Santen ◽  
Karri L. Grob ◽  
Seetha U. Monrad ◽  
Caren M. Stalburg ◽  
Gary Smith ◽  
...  
Keyword(s):  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause ◽  
Analysis Process ◽  
Examination Quality

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

Root Cause Analysis of Glovebox Glove Failure

2007 ◽  
Author(s):  
Y. H. Park ◽  
Michael Cournoyer
Keyword(s):  
Safety Concern ◽  
National Laboratory ◽  
Root Cause Analysis ◽  
Nuclear Materials ◽  
Alamos National Laboratory ◽  
Cause Analysis ◽  
Los Alamos National Laboratory ◽  
Root Cause ◽  
Analysis Process

The Nuclear Materials Technology (NMT) Division has the largest inventory of glovebox gloves at Los Alamos National Laboratory (LANL). Consequently, the minimization of unplanned breaches of the glove material, typically resulting in glove failures, is a significant safety concern in the daily operations in NMT Division facilities. To investigate processes and procedures that minimize unplanned breaches in the glovebox, information on glovebox glove failures has been compiled from formal records and analyzed using statistical methods. Based on these research results, the next step of the research is to identify root causes of glove failures and the actions adequate to prevent recurrence. In this paper, root cause analysis was conducted for a cleanup breach case study to demonstrate the computerized root cause analysis process. Based on analysis results, effective recommendations were generated.

Hamilton Acute Pain Service Safety Study

2014 ◽  
Vol 120 (1) ◽  
pp. 97-109 ◽  
Author(s):  
James E. Paul ◽  
Norman Buckley ◽  
Richard F. McLean ◽  
Karen Antoni ◽  
David Musson ◽  
...  
Keyword(s):  
Acute Pain ◽  
Root Cause Analysis ◽  
Acute Pain Service ◽  
Patient Controlled Analgesia ◽  
Cause Analysis ◽  
Root Cause ◽  
Analysis Process ◽  
Severe Hypotension ◽  
Before And After ◽  
Address System

Abstract Background: Although intravenous patient-controlled analgesia opioids and epidural analgesia offer improved analgesia for postoperative patients treated on an acute pain service, these modalities also expose patients to some risk of serious morbidity and even mortality. Root cause analysis, a process for identifying the causal factor(s) that underlie an adverse event, has the potential to identify and address system issues and thereby decrease the chance of recurrence of these complications. Methods: This study was designed to compare the incidence of adverse events on an acute pain service in three hospitals, before and after the introduction of a formal root cause analysis process. The “before” cohort included all patients with pain from February 2002 to July 2007. The “after” cohort included all patients with pain from January 2009 to December 2009. Results: A total of 35,384 patients were tracked over the 7 yr of this study. The after cohort showed significant reductions in the overall event rate (1.47 vs. 2.35% or 1 in 68 vs. 1 in 42, the rate of respiratory depression (0.41 vs. 0.71%), the rate of severe hypotension (0.78 vs. 1.34%), and the rate of patient-controlled analgesia pump programming errors (0.0 vs. 0.08%). Associated with these results, the incidence of severe pain increased from 6.5 to 10.5%. To achieve these results, 26 unique recommendations were made of which 23 being completed, 1 in progress, and 2 not completed. Conclusions: Formal root cause analysis was associated with an improvement in the safety of patients on a pain service. The process was effective in giving credibility to recommendations, but addressing all the action plans proved difficult with available resources.

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