Literature DB >> 29319273

How to undertake a root cause analysis investigation to improve patient safety.

Elizabeth Haxby1, Caroline Shuldham2.   

Abstract

RATIONALE AND KEY POINTS: Root cause analysis is a tool that can be used when determining how and why a patient safety incident has occurred. Incidents that usually require a root cause analysis include the unexpected death of a patient, serious pressure ulcers, falls that result in injury, and some infections and medication errors. This article outlines the stages of the investigation process for undertaking a root cause analysis. REFLECTIVE ACTIVITY: 'How to' articles can help update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of. ©2018 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.

Entities:  

Keywords:  clinical procedures; clinical skills; duty of candour; incident reporting; investigations; patient safety; root cause analysis; service improvement

Year:  2018        PMID: 29319273     DOI: 10.7748/ns.2018.e10859

Source DB:  PubMed          Journal:  Nurs Stand        ISSN: 0029-6570


  2 in total

1.  Patient Safety Incident Reporting In Indonesia: An Analysis Using World Health Organization Characteristics For Successful Reporting.

Authors:  Inge Dhamanti; Sandra Leggat; Simon Barraclough; Benny Tjahjono
Journal:  Risk Manag Healthc Policy       Date:  2019-12-12

2.  Root Cause Analysis to Identify Medication and Non-Medication Strategies to Prevent Infection-Related Hospitalizations from Australian Residential Aged Care Services.

Authors:  Janet K Sluggett; Samanta Lalic; Sarah M Hosking; Brett Ritchie; Jennifer McLoughlin; Terry Shortt; Leonie Robson; Tina Cooper; Kelly A Cairns; Jenni Ilomäki; Renuka Visvanathan; J Simon Bell
Journal:  Int J Environ Res Public Health       Date:  2020-05-08       Impact factor: 3.390

  2 in total

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