With increasing emphasis on patient safety/quality improvement, health care systems are
mirroring industry in the implementation of root cause analysis (RCA) for the identification …

Article-at-a-Glance Background Root cause analysis (RCA) is an analysis framework used
in health care to determine the systemic causes and prevent recurrences of adverse events …

Introduction Historically, the surgical morbidity and mortality conference (SMMC) has been a
core educational venue, a qualityassurance (QA) tool, and a way to socialize a surgical …

Article-at-a-Glance Background The patient safety program in the Department of Veterans
Affairs (VA) began in 1998, when the National Center for Patient Safety (NCPS) was …

The quality of care delivered by orthopedic surgeons continues to grow in importance.
Multiple orthopedic programs, organizations, and committees have been created to measure …

Providing quality patient care is a basic tenant of medical and surgical practice. Multiple
orthopaedic programs, including The Patient Safety Committee of the American Academy of …

Medical errors represent a serious public health problem and pose a threat to patient safety.
All patients are potentially vulnerable, therefore medical errors are costly from a human …

The root cause analysis (RCA) process is used to investigate adverse events. However, it
may not reduce the risk of recurrence as effectively as intended. The authors propose …

The conversation related to patient safety has gained currency in the last decade and
incident investigation processes have been implemented by health care organizations …

Article-at-a-Glance Background Empirical evidence is limited that root cause analysis (RCA),
an event analysis tool used in health care to evaluate the systemic factors that lead to …