An analysis of adverse events in the rehabilitation department: using the veterans affairs root cause analysis system

GW Hagley, PD Mills, B Shiner, RR Hemphill - Physical therapy, 2018 - academic.oup.com
Background Root cause analyses (RCA) are often completed in health care settings to
determine causes of adverse events (AEs). RCAs result in action plans designed to mitigate …

Trust‐level risk evaluation and risk control guidance in the NHS east of England

AJ Card, JR Ward, PJ Clarkson - Risk Analysis, 2014 - Wiley Online Library
In recent years, the healthcare sector has adopted the use of operational risk assessment
tools to help understand the systems issues that lead to patient safety incidents. But …

Hamilton acute pain service safety study: using root cause analysis to reduce the incidence of adverse events

JE Paul, N Buckley, RF McLean, K Antoni… - …, 2014 - pubs.asahq.org
Background: Although intravenous patient-controlled analgesia opioids and epidural
analgesia offer improved analgesia for postoperative patients treated on an acute pain …

[图书][B] Medical error and harm: Understanding, prevention, and control

M Jenicek - 2010 - taylorfrancis.com
Recent debate over healthcare and its spiraling costs has brought medical error into the
spotlight as an indicator of everything that is ineffective, inhumane, and wasteful about …

Team experiences of the root cause analysis process after a sentinel event: a qualitative case study

S Liepelt, H Sundal, R Kirchhoff - BMC Health Services Research, 2023 - Springer
Background Root cause analysis (RCA) is a systematic approach, typically involving several
stages, used in healthcare to identify the underlying causes of a medical error or sentinel …

Making sense of root cause analysis investigations of surgery-related adverse events

BR Cassin, PR Barach - Surgical Clinics, 2012 - surgical.theclinics.com
The conversation related to patient safety has gained currency in the last decade and
incident investigation processes have been implemented by health care organizations …

Assessment of Patient Matters in Healthcare Facilities

F Moldovan, L Moldovan - Healthcare, 2024 - mdpi.com
Background and Objectives: Ensuring the sustainability of healthcare facilities requires the
evaluation of patient matters with appropriate methods and tools. The objective of this …

[PDF][PDF] The shortcomings of existing root cause analysis tools

H Yuniarto - Proceedings of the World Congress on Engineering, 2012 - iaeng.org
The effective use of the Six Sigma problem-solving methodology is strongly influenced by
the efficacy of the Root Cause Analysis tools, the tools used for performing the Analyze …

Study on preventing adverse events in neonates (SEPREVEN): a stepped-wedge randomised controlled trial to reduce adverse event rates in the NICU

L Caeymaex, C Lebeaux, JC Roze, C Danan… - Medicine, 2020 - journals.lww.com
Introduction: Adverse events (AE) in care are recognized as a leading cause of mortality and
injury in patients. Improving patientsL safety is difficult to achieve. Therefore, innovative …

Suicide as an incident of severe patient harm: a retrospective cohort study of investigations after suicide in Swedish healthcare in a 13-year perspective

E Fröding, BA Gäre, Å Westrin, A Ros - BMJ open, 2021 - bmjopen.bmj.com
Objectives To explore how mandatory reporting to the supervisory authority of suicides
among recipients of healthcare services has influenced associated investigations conducted …