Root Cause Analysis: Learning from Adverse Safety Events
نویسندگان
چکیده
منابع مشابه
Learning from Adverse Events in Obstetrics: Is a Standardized Computer Tool an Effective Strategy for Root Cause Analysis?
OBJECTIVE Adverse events occur in up to 10% of obstetric cases, and up to one half of these could be prevented. Case reviews and root cause analysis using a structured tool may help health care providers to learn from adverse events and to identify trends and recurring systems issues. We sought to establish the reliability of a root cause analysis computer application called Standardized Clinic...
متن کاملHamilton acute pain service safety study: using root cause analysis to reduce the incidence of adverse events.
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 identi...
متن کاملRoot Cause and Error Analysis
Error is an inevitable part of life and cannot be completely eliminated, but it can be minimized. A root cause analysis is a technique for understanding the systematic error causes that is involved beyond a person or people to implement an errors and including field and environmental causes of errors when occur in this situation too. An important factor of an error occurrence is a root cause (c...
متن کاملSystem-wide learning from root cause analysis: a report from the New South Wales Root Cause Analysis Review Committee.
BACKGROUND Preventable errors are common in healthcare. Over the last decade, Root Cause Analysis (RCA) has become a key tool for healthcare services to investigate adverse events and try to prevent them from happening again. The purpose of this paper is to highlight the work of the New South Wales (NSW) RCA Review Committee. The benefits of correctly classifying, aggregating and disseminating ...
متن کاملAdverse events in healthcare: learning from mistakes.
Large national reviews of patient charts estimate that approximately 10% of hospital admissions are associated with an adverse event (defined as an injury resulting in prolonged hospitalization, disability or death, caused by healthcare management). Apart from having a significant impact on patient morbidity and mortality, adverse events also result in increased healthcare costs due to longer h...
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ژورنال
عنوان ژورنال: RadioGraphics
سال: 2015
ISSN: 0271-5333,1527-1323
DOI: 10.1148/rg.2015150067