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| example of root cause analysis in healthcare: Making Healthcare Safe Lucian L. Leape, 2021-05-28 This unique and engaging open access title provides a compelling and ground-breaking account of the patient safety movement in the United States, told from the perspective of one of its most prominent leaders, and arguably the movement’s founder, Lucian L. Leape, MD. Covering the growth of the field from the late 1980s to 2015, Dr. Leape details the developments, actors, organizations, research, and policy-making activities that marked the evolution and major advances of patient safety in this time span. In addition, and perhaps most importantly, this book not only comprehensively details how and why human and systems errors too often occur in the process of providing health care, it also promotes an in-depth understanding of the principles and practices of patient safety, including how they were influenced by today’s modern safety sciences and systems theory and design. Indeed, the book emphasizes how the growing awareness of systems-design thinking and the self-education and commitment to improving patient safety, by not only Dr. Leape but a wide range of other clinicians and health executives from both the private and public sectors, all converged to drive forward the patient safety movement in the US. Making Healthcare Safe is divided into four parts: I. In the Beginning describes the research and theory that defined patient safety and the early initiatives to enhance it. II. Institutional Responses tells the stories of the efforts of the major organizations that began to apply the new concepts and make patient safety a reality. Most of these stories have not been previously told, so this account becomes their histories as well. III. Getting to Work provides in-depth analyses of four key issues that cut across disciplinary lines impacting patient safety which required special attention. IV. Creating a Culture of Safety looks to the future, marshalling the best thinking about what it will take to achieve the safe care we all deserve. Captivatingly written with an “insider’s” tone and a major contribution to the clinical literature, this title will be of immense value to health care professionals, to students in a range of academic disciplines, to medical trainees, to health administrators, to policymakers and even to lay readers with an interest in patient safety and in the critical quest to create safe care. |
| example of root cause analysis in healthcare: Root Cause Analysis (RCA) for the Improvement of Healthcare Systems and Patient Safety David Allison, CPPS, Harold Peters, P.Eng., 2021-08-24 The book follows a proven training outline, including real-life examples and exercises, to teach healthcare professionals and students how to lead effective and successful Root Cause Analysis (RCA) to eliminate patient harm. This book discusses the need for RCA in the healthcare sector, providing practical advice for its facilitation. It addresses when to use RCA, how to create effective RCA action plans, and how to prevent common RCA failures. An RCA training curriculum is also included. This book is intended for those leading RCAs of patient harm events, leaders, students, and patient safety advocates who are interested in gaining more knowledge about RCA in healthcare. |
| example of root cause analysis in healthcare: Communities in Action National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Population Health and Public Health Practice, Committee on Community-Based Solutions to Promote Health Equity in the United States, 2017-04-27 In the United States, some populations suffer from far greater disparities in health than others. Those disparities are caused not only by fundamental differences in health status across segments of the population, but also because of inequities in factors that impact health status, so-called determinants of health. Only part of an individual's health status depends on his or her behavior and choice; community-wide problems like poverty, unemployment, poor education, inadequate housing, poor public transportation, interpersonal violence, and decaying neighborhoods also contribute to health inequities, as well as the historic and ongoing interplay of structures, policies, and norms that shape lives. When these factors are not optimal in a community, it does not mean they are intractable: such inequities can be mitigated by social policies that can shape health in powerful ways. Communities in Action: Pathways to Health Equity seeks to delineate the causes of and the solutions to health inequities in the United States. This report focuses on what communities can do to promote health equity, what actions are needed by the many and varied stakeholders that are part of communities or support them, as well as the root causes and structural barriers that need to be overcome. |
| example of root cause analysis in healthcare: Root Cause Analysis, Second Edition Bjørn Andersen, Tom Fagerhaug, 2006-01-01 This updated and expanded edition discusses many different tools for root cause analysis and presents them in an easy-to-follow structure: a general description of the tool, its purpose and typical applications, the procedure when using it, an example of its use, a checklist to help you make sure if is applied properly, and different forms and templates (that can also be found on an accompanying CD-ROM). The examples used are general enough to apply to any industry or market. The layout of the book has been designed to help speed your learning. Throughout, the authors have split the pages into two halves: the top half presents key concepts using brief languagealmost keywordsand the bottom half uses examples to help explain those concepts. A roadmap in the margin of every page simplifies navigating the book and searching for specific topics. The book is suited for employees and managers at any organizational level in any type of industry, including service, manufacturing, and the public sector. |
| example of root cause analysis in healthcare: Root Cause Analysis Handbook ABS Consulting, Lee N. Vanden Heuvel, Donald K. Lorenzo, Laura O. Jackson, Walter E. Hanson, James J. Rooney, David A. Walker, 2014-10-01 Are you trying to improve performance, but find that the same problems keep getting in the way? Safety, health, environmental quality, reliability, production, and security are at stake. You need the long-term planning that will keep the same issues from recurring. Root Cause Analysis Handbook: A Guide to Effective Incident Investigation is a powerful tool that gives you a detailed step-by-step process for learning from experience. Reach for this handbook any time you need field-tested advice for investigating, categorizing, reporting and trending, and ultimately eliminating the root causes of incidents. It includes step-by-step instructions, checklists, and forms for performing an analysis and enables users to effectively incorporate the methodology and apply it to a variety of situations. Using the structured techniques in the Root Cause Analysis Handbook, you will: Understand why root causes are important. Identify and define inherent problems. Collect data for problem-solving. Analyze data for root causes. Generate practical recommendations. The third edition of this global classic is the most comprehensive, all-in-one package of book, downloadable resources, color-coded RCA map, and licensed access to online resources currently available for Root Cause Analysis (RCA). Called by users the best resource on the subject and in a league of its own. Based on globally successful, proprietary methodology developed by ABS Consulting, an international firm with 50 years' experience in 35 countries. Root Cause Analysis Handbook is widely used in corporate training programs and college courses all over the world. If you are responsible for quality, reliability, safety, and/or risk management, you'll want this comprehensive and practical resource at your fingertips. The book has also been selected by the American Society for Quality (ASQ) and the Risk and Insurance Society (RIMS) as a must have for their members. |
| example of root cause analysis in healthcare: Root Cause Analysis and Improvement in the Healthcare Sector Bjørn Andersen, Marti Beltz, 2009-11-09 Healthcare organizations and professionals have long needed a straightforward workbook to facilitate the process of root cause analysis (RCA). While other industries employ the RCA tools liberally and train facilitators thoroughly, healthcare has lagged in establishing and resourcing a quality culture. Presently, a growing number of third-party stakeholders are holding access to accreditation and reimbursement pending demonstration of a full response to events outside of expected practice. An increasing number of exceptions to healthcare practice have precipitated a strong response advocating the use of proven quality tools in the industry. In addition, the industry has now expanded its scope beyond the hospital walls to many ancillary healthcare facilities with little experience in implementing quality tools. This book responds to the demand for a RCA workbook written specifically for healthcare, yet still broad in its definition of the industry. This book contains everything that the typical RCA leader in healthcare requires: A text specific to healthcare, but using the broadest definition of the industry to include not only acute care hospitals, but rehabilitation facilities, long-term care facilities, outpatient surgery centers, ambulatory services, and general office practices. A workbook-style format that walks through the process, step-by-step. Straightforward text without “sidebars,” “tables,” and “tips.” Worksheets are provided at the end of the book to reduce reader distraction within the text. A wide range of real-world examples. Format for use by the most naive of users and most basic of processes, as well as a separate section for more advanced users or more complex issues. Templates, both print and electronic, included for the reader’s use. Ready-to-use educational materials with scripting to enable the user to train others and garner support for the use of the techniques. Background text for users in leadership to understand the tools in the larger context of healthcare improvement. Up-to-date information on the latest in the use of RCA in satisfying mandatory reporting requirements and slaying the myth that the process is onerous and fraught with barriers. Background text and tools/process are separated to facilitate the readers’ specific needs. Healthcare leaders can appreciate the current context and requirements without wading through the actual techniques; end-users can begin learning the skills without wading through dense administrative text. Language and tone promoting the use of the tools for improvement of processes that have experienced exceptions, as opposed to assigning blame for errors. Attention to process ownership, training, and resourcing. And, most importantly, thorough description of the improvement process as well as the analysis. |
| example of root cause analysis in healthcare: Root Cause Analysis and Improvement in the Healthcare Sector Bjorn Andersen, Martha Ellen Keyes Beltz, Tom Natland Fagerhaug, 2009-11-09 Healthcare organizations and professionals have long needed a straightforward workbook to facilitate the process of root cause analysis (RCA). While other industries employ the RCA tools liberally and train facilitators thoroughly, healthcare has lagged in establishing and resourcing a quality culture. Presently, a growing number of third-party stakeholders are holding access to accreditation and reimbursement pending demonstration of a full response to events outside of expected practice. An increasing number of exceptions to healthcare practice have precipitated a strong response advocating the use of proven quality tools in the industry. In addition, the industry has now expanded its scope beyond the hospital walls to many ancillary healthcare facilities with little experience in implementing quality tools. This book responds to the demand for a RCA workbook written specifically for healthcare, yet still broad in its definition of the industry. This book contains everything that the typical RCA leader in healthcare requires: A text specific to healthcare, but using the broadest definition of the industry to include not only acute care hospitals, but rehabilitation facilities, long-term care facilities, outpatient surgery centers, ambulatory services, and general office practices. A workbook-style format that walks through the process, step-by-step. Straightforward text without “sidebars,” “tables,” and “tips.” Worksheets are provided at the end of the book to reduce reader distraction within the text. A wide range of real-world examples. Format for use by the most naive of users and most basic of processes, as well as a separate section for more advanced users or more complex issues. Templates, both print and electronic, included for the reader’s use. Ready-to-use educational materials with scripting to enable the user to train others and garner support for the use of the techniques. Background text for users in leadership to understand the tools in the larger context of healthcare improvement. Up-to-date information on the latest in the use of RCA in satisfying mandatory reporting requirements and slaying the myth that the process is onerous and fraught with barriers. Background text and tools/process are separated to facilitate the readers’ specific needs. Healthcare leaders can appreciate the current context and requirements without wading through the actual techniques; end-users can begin learning the skills without wading through dense administrative text. Language and tone promoting the use of the tools for improvement of processes that have experienced exceptions, as opposed to assigning blame for errors. Attention to process ownership, training, and resourcing. And, most importantly, thorough description of the improvement process as well as the analysis. |
| example of root cause analysis in healthcare: Improving Diagnosis in Health Care National Academies of Sciences, Engineering, and Medicine, Institute of Medicine, Board on Health Care Services, Committee on Diagnostic Error in Health Care, 2015-12-29 Getting the right diagnosis is a key aspect of health care - it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative. Improving Diagnosis in Health Care, a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001), finds that diagnosis-and, in particular, the occurrence of diagnostic errorsâ€has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety. |
| example of root cause analysis in healthcare: Advances in Patient Safety Kerm Henriksen, 2005 v. 1. Research findings -- v. 2. Concepts and methodology -- v. 3. Implementation issues -- v. 4. Programs, tools and products. |
| example of root cause analysis in healthcare: Public Health Behind Bars Robert Greifinger, 2007-10-04 Public Health Behind Bars From Prisons to Communities examines the burden of illness in the growing prison population, and analyzes the impact on public health as prisoners are released. This book makes a timely case for correctional health care that is humane for those incarcerated and beneficial to the communities they reenter. |
| example of root cause analysis in healthcare: Clinical Engineering Handbook Joseph F. Dyro, 2004-08-27 As the biomedical engineering field expands throughout the world, clinical engineers play an ever more important role as the translator between the worlds of the medical, engineering, and business professionals. They influence procedure and policy at research facilities, universities and private and government agencies including the Food and Drug Administration and the World Health Organization. Clinical engineers were key players in calming the hysteria over electrical safety in the 1970s and Y2K at the turn of the century and continue to work for medical safety. This title brings together all the important aspects of Clinical Engineering. It provides the reader with prospects for the future of clinical engineering as well as guidelines and standards for best practice around the world. |
| example of root cause analysis in healthcare: Root Cause Analysis in Health Care Joint Commission Resources, Inc Staff, 2005-05-01 |
| example of root cause analysis in healthcare: Crossing the Quality Chasm Institute of Medicine, Committee on Quality of Health Care in America, 2001-07-19 Second in a series of publications from the Institute of Medicine's Quality of Health Care in America project Today's health care providers have more research findings and more technology available to them than ever before. Yet recent reports have raised serious doubts about the quality of health care in America. Crossing the Quality Chasm makes an urgent call for fundamental change to close the quality gap. This book recommends a sweeping redesign of the American health care system and provides overarching principles for specific direction for policymakers, health care leaders, clinicians, regulators, purchasers, and others. In this comprehensive volume the committee offers: A set of performance expectations for the 21st century health care system. A set of 10 new rules to guide patient-clinician relationships. A suggested organizing framework to better align the incentives inherent in payment and accountability with improvements in quality. Key steps to promote evidence-based practice and strengthen clinical information systems. Analyzing health care organizations as complex systems, Crossing the Quality Chasm also documents the causes of the quality gap, identifies current practices that impede quality care, and explores how systems approaches can be used to implement change. |
| example of root cause analysis in healthcare: Medical Device Use Error Michael Wiklund, Andrea Dwyer, Erin Davis, 2016-01-06 Medical Device Use Error: Root Cause Analysis offers practical guidance on how to methodically discover and explain the root cause of a use error-a mistake-that occurs when someone uses a medical device. Covering medical devices used in the home and those used in clinical environments, the book presents informative case studies about the use errors |
| example of root cause analysis in healthcare: Resilient Health Care, Volume 3 Jeffrey Braithwaite, Robert L. Wears, Erik Hollnagel, 2016-10-03 This book is the 3rd volume in the Resilient Health Care series. Resilient health care is a product of both the policy and managerial efforts to organize, fund and improve services, and the clinical care which is delivered directly to patients. This volume continues the lines of thought in the first two books. Where the first volume provided the rationale and basic concepts of RHC and the second teased out the everyday clinical activities which adjust and vary to create safe care, this book will look more closely at the connections between the sharp and blunt ends. Doing so will break new ground, since the systematic study in patient safety to date with few exceptions has been limited. |
| example of root cause analysis in healthcare: Patient Safety Institute of Medicine, Board on Health Care Services, Committee on Data Standards for Patient Safety, 2003-12-20 Americans should be able to count on receiving health care that is safe. To achieve this, a new health care delivery system is needed †a system that both prevents errors from occurring, and learns from them when they do occur. The development of such a system requires a commitment by all stakeholders to a culture of safety and to the development of improved information systems for the delivery of health care. This national health information infrastructure is needed to provide immediate access to complete patient information and decision-support tools for clinicians and their patients. In addition, this infrastructure must capture patient safety information as a by-product of care and use this information to design even safer delivery systems. Health data standards are both a critical and time-sensitive building block of the national health information infrastructure. Building on the Institute of Medicine reports To Err Is Human and Crossing the Quality Chasm, Patient Safety puts forward a road map for the development and adoption of key health care data standards to support both information exchange and the reporting and analysis of patient safety data. |
| example of root cause analysis in healthcare: Unifying the Applications and Foundations of Biomedical and Health Informatics J. Mantas, A. Hasman, G. Gallos, 2016-07-21 Informatics and technology have become an intrinsic part of healthcare management in recent years; it is almost impossible to imagine a modern healthcare system without them. This book presents the proceedings of the 14th annual International Conference on Informatics, Management and Technology in Healthcare (ICIMTH), held in Athens, Greece, in July 2016. The conference treats the field of biomedical informatics in a very broad framework, and the 68 full papers included here examine the research and applications outcomes of informatics from cell to population, including a number of technologies such as imaging, sensors, mobile communications, biomedical equipment and management, as well as legal and societal issues related to the application of health informatics. The book is divided into sections: Biomedical Technology; Clinical Informatics; E-learning and Education; Formalisation of Knowledge, Ontologies, Clinical Guidelines and Standards of Healthcare; Health Informatics; Healthcare Management and Public Health; mHealth and Telemedicine; and Social Media and Health. Also included are two keynote speeches. Covering a wide spectrum of applications, the book will be of interest to all those working in the design, management and delivery of healthcare services whose work involves the development or use of biomedical informatics. |
| example of root cause analysis in healthcare: Pediatric Board Study Guide Osama Naga, 2015-03-27 Covers the most frequently asked and tested points on the pediatric board exam. Each chapter offers a quick review of specific diseases and conditions clinicians need to know during the patient encounter. Easy-to-use and comprehensive, clinicians will find this guide to be the ideal final resource needed before taking the pediatric board exam. |
| example of root cause analysis in healthcare: Root Cause Analysis, Second Edition Duke Okes, 2019-02-06 This best-seller can help anyone whose role is to try to find specific causes for failures. It provides detailed steps for solving problems, focusing more heavily on the analytical process involved in finding the actual causes of problems. It does this using figures, diagrams, and tools useful for helping to make our thinking visible. This increases our ability to see what is truly significant and to better identify errors in our thinking. In the sections on finding root causes, this second edition now includes: more examples on the use of multi-vari charts; how thought experiments can help guide data interpretation; how to enhance the value of the data collection process; cautions for analyzing data; and what to do if one cant find the causes. In its guidance on solution identification, biomimicry and TRIZ have been added as potential solution identification techniques. In addition, the appendices have been revised to include: an expanded breakdown of the 7 Ms, which includes more than 50 specific possible causes; forms for tracking causes and solutions, which can help maintain alignment of actions; techniques for how to enhance the interview process; and example responses to problem situations that the reader can analyze for appropriateness. |
| example of root cause analysis in healthcare: Patient Safety Russell Kelsey, 2023-08-28 The second edition of this well-received book, the first to provide detailed guidance on how to conduct incident investigations in primary care, has been thoroughly revised and updated throughout to reflect the current nomenclature for different aspects of the investigatory process in the UK and the latest format for incident reporting. Key features: Explains how to recognise a serious clinical incident, how to conduct a root cause analysis (RCA) investigation, and how and when duty of candour applies Covers the technical aspects of serious incident recognition and report writing Includes a wealth of practical advice and 'top tips', including how to manage the common pitfalls in writing reports Offers practical advice as well as some new and innovative tools to help make the RCA process easier to follow Explores the all-important human factors in clinical incidents in detail, with multiple examples and worked-through cases studies as well as in-depth sample reports and analysis. At a time of increasing regulatory scrutiny and medico-legal risk, in which failure to manage appropriately can have serious consequences both for service organisations and for individuals involved, this concise and convenient book continues to provide a master class for anyone performing RCA and aiming to demonstrate learning and service improvement in response to serious clinical incidents. It is essential reading for any clinical or governance leads in primary care, including GP practices, 'out-of-hours', urgent care centres, prison health and NHS 111. It also offers valuable insights to any clinician who is in training or working at the coal face who wishes to understand how serious clinical incidents are investigated and managed. |
| example of root cause analysis in healthcare: The Great Mental Models, Volume 1 Shane Parrish, Rhiannon Beaubien, 2024-10-15 Discover the essential thinking tools you’ve been missing with The Great Mental Models series by Shane Parrish, New York Times bestselling author and the mind behind the acclaimed Farnam Street blog and “The Knowledge Project” podcast. This first book in the series is your guide to learning the crucial thinking tools nobody ever taught you. Time and time again, great thinkers such as Charlie Munger and Warren Buffett have credited their success to mental models–representations of how something works that can scale onto other fields. Mastering a small number of mental models enables you to rapidly grasp new information, identify patterns others miss, and avoid the common mistakes that hold people back. The Great Mental Models: Volume 1, General Thinking Concepts shows you how making a few tiny changes in the way you think can deliver big results. Drawing on examples from history, business, art, and science, this book details nine of the most versatile, all-purpose mental models you can use right away to improve your decision making and productivity. This book will teach you how to: Avoid blind spots when looking at problems. Find non-obvious solutions. Anticipate and achieve desired outcomes. Play to your strengths, avoid your weaknesses, … and more. The Great Mental Models series demystifies once elusive concepts and illuminates rich knowledge that traditional education overlooks. This series is the most comprehensive and accessible guide on using mental models to better understand our world, solve problems, and gain an advantage. |
| example of root cause analysis in healthcare: Medication Errors Michael Richard Cohen, 2007 In this expanded 600+ page edition, Dr. Cohen brings together some 30 experts from pharmacy, medicine, nursing, and risk management to provide the most current thinking about the causes of medication errors and strategies to prevent them. |
| example of root cause analysis in healthcare: Patient Safety Handbook Barbara J. Youngberg, 2013 Examines the newest scientific advances in the science of safety. |
| example of root cause analysis in healthcare: Root Cause Analysis (RCA) for the Improvement of Healthcare Systems and Patient Safety David Allison, CPPS, Harold Peters, P.Eng., 2021-08-23 The book follows a proven training outline, including real-life examples and exercises, to teach healthcare professionals and students how to lead effective and successful Root Cause Analysis (RCA) to eliminate patient harm. This book discusses the need for RCA in the healthcare sector, providing practical advice for its facilitation. It addresses when to use RCA, how to create effective RCA action plans, and how to prevent common RCA failures. An RCA training curriculum is also included. This book is intended for those leading RCAs of patient harm events, leaders, students, and patient safety advocates who are interested in gaining more knowledge about RCA in healthcare. |
| example of root cause analysis in healthcare: Fundamentals of Health Care Improvement Gregory S. Ogrinc, Linda Headrick, Amy J. Barton, Mary A. Dolansky, Wendy S. Madigosky, Rebecca S. Miltner, 2022 |
| example of root cause analysis in healthcare: Understanding Patient Safety, Second Edition Robert Wachter, 2012-05-23 Complete coverage of the core principles of patient safety Understanding Patient Safety, 2e is the essential text for anyone wishing to learn the key clinical, organizational, and systems issues in patient safety.The book is filled with valuable cases and analyses, as well as up-to-date tables, graphics, references, and tools -- all designed to introduce the patient safety field to medical trainees, and be the go-to book for experienced clinicians and non-clinicians alike. Features NEW chapter on the critically important role of checklists in medical practice NEW case examples throughout Expanded coverage of the role of computers in patient safety and outcomes Expanded coverage of new patient initiatives from the Joint Commission |
| example of root cause analysis in healthcare: Knowledge Solutions Olivier Serrat, 2017-05-22 This book is open access under a CC BY-NC 3.0 IGO license. This book comprehensively covers topics in knowledge management and competence in strategy development, management techniques, collaboration mechanisms, knowledge sharing and learning, as well as knowledge capture and storage. Presented in accessible “chunks,” it includes more than 120 topics that are essential to high-performance organizations. The extensive use of quotes by respected experts juxtaposed with relevant research to counterpoint or lend weight to key concepts; “cheat sheets” that simplify access and reference to individual articles; as well as the grouping of many of these topics under recurrent themes make this book unique. In addition, it provides scalable tried-and-tested tools, method and approaches for improved organizational effectiveness. The research included is particularly useful to knowledge workers engaged in executive leadership; research, analysis and advice; and corporate management and administration. It is a valuable resource for those working in the public, private and third sectors, both in industrialized and developing countries. |
| example of root cause analysis in healthcare: Patient Safety Culture Dr Patrick Waterson, 2014-11-28 How safe are hospitals? Why do some hospitals have higher rates of accident and errors involving patients? How can we accurately measure and assess staff attitudes towards safety? How can hospitals and other healthcare environments improve their safety culture and minimize harm to patients? These and other questions have been the focus of research within the area of Patient Safety Culture (PSC) in the last decade. More and more hospitals and healthcare managers are trying to understand the nature of the culture within their organisations and implement strategies for improving patient safety. The main purpose of this book is to provide researchers, healthcare managers and human factors practitioners with details of the latest developments within the theory and application of PSC within healthcare. It brings together contributions from the most prominent researchers and practitioners in the field of PSC and covers the background to work on safety culture (e.g. measuring safety culture in industries such as aviation and the nuclear industry), the dominant theories and concepts within PSC, examples of PSC tools, methods of assessment and their application, and details of the most prominent challenges for the future in the area. Patient Safety Culture: Theory, Methods and Application is essential reading for all of the professional groups involved in patient safety and healthcare quality improvement, filling an important gap in the current market. |
| example of root cause analysis in healthcare: Management and Leadership – A Guide for Clinical Professionals Sanjay Patole, 2015-01-05 This book will provide anyone with an interest in the clinic with a basic guide on those things that are not taught during medical school or any other pre-clinical trainings. The line-up of authors was carefully assembled to include experts in all respective fields to give this volume the authority it requires to be a relevant text for many. |
| example of root cause analysis in healthcare: Textbook of Patient Safety and Clinical Risk Management Liam Donaldson, Walter Ricciardi, Susan Sheridan, Riccardo Tartaglia, 2020-12-14 Implementing safety practices in healthcare saves lives and improves the quality of care: it is therefore vital to apply good clinical practices, such as the WHO surgical checklist, to adopt the most appropriate measures for the prevention of assistance-related risks, and to identify the potential ones using tools such as reporting & learning systems. The culture of safety in the care environment and of human factors influencing it should be developed from the beginning of medical studies and in the first years of professional practice, in order to have the maximum impact on clinicians' and nurses' behavior. Medical errors tend to vary with the level of proficiency and experience, and this must be taken into account in adverse events prevention. Human factors assume a decisive importance in resilient organizations, and an understanding of risk control and containment is fundamental for all medical and surgical specialties. This open access book offers recommendations and examples of how to improve patient safety by changing practices, introducing organizational and technological innovations, and creating effective, patient-centered, timely, efficient, and equitable care systems, in order to spread the quality and patient safety culture among the new generation of healthcare professionals, and is intended for residents and young professionals in different clinical specialties. |
| example of root cause analysis in healthcare: Accident Precursor Analysis and Management National Academy of Engineering, 2004-09-16 In the aftermath of catastrophes, it is common to find prior indicators, missed signals, and dismissed alerts that, had they been recognized and appropriately managed before the event, could have resulted in the undesired event being averted. These indicators are typically called precursors. Accident Precursor Analysis and Management: Reducing Technological Risk Through Diligence documents various industrial and academic approaches to detecting, analyzing, and benefiting from accident precursors and examines public-sector and private-sector roles in the collection and use of precursor information. The book includes the analysis, findings and recommendations of the authoring NAE committee as well as eleven individually authored background papers on the opportunity of precursor analysis and management, risk assessment, risk management, and linking risk assessment and management. |
| example of root cause analysis in healthcare: TapRooT Mark Paradies, Linda Unger, 2000 |
| example of root cause analysis in healthcare: Patient Safety in Surgery Philip F. Stahel, Cyril Mauffrey, 2014-08-20 In general, surgeons strive to achieve excellent results and ideal patient outcomes, however, this noble task is frequently failed. For patients, surgical complications are analogous to “friendly fire” in wartime. Both scenarios imply that harm is unintentionally done by somebody whose aim was to help. Interestingly, adverse events resulting from surgical interventions are more frequently related to system errors and a communication breakdown among providers, rather than to the imminent threat of the surgical blade “gone wrong”. Patient Safety in Surgery aims to increase the safety and quality of care for patients undergoing surgical procedures in all fields of surgery. Patient Safety in Surgery, covers all aspects related to patient safety in surgery, including pertinent issues of interest to surgeons, medical trainees (students, residents, and fellows), nurses, anaesthesiologists, patients, patient families, advocacy groups, and medicolegal experts. |
| example of root cause analysis in healthcare: The ASQ Pocket Guide to Root Cause Analysis Bjørn Andersen, Tom Natland Fagerhaug, 2013-11-06 All organizations experience unintended variation and its consequences. Such problems exist within a broad range of scope, persistence, and severity across different industries. Some problems cause minor nuisances, others leads to loss of customers or money, others yet can be a matter of life and death. The purpose of this pocket guide is to provide you with easily accessible knowledge about the art of problem solving, with a specific focus on identifying and eliminating root causes of problems. Root cause analysis is a skill that absolutely everybody should master, irrespective of which sector you work in, what educational background you have, and which position in the organization you hold. The content in this little pocket guide can contribute to disseminating this skill a little further in the world. |
| example of root cause analysis in healthcare: Healthcare Quality Management Zachary Pruitt, PhD, MHA, CPH, Candace S. Smith, PhD, RN, NEA-BC, Eddie Perez-Ruberte, 2020-02-28 Healthcare Quality Management: A Case Study Approach is the first comprehensive case-based text combining essential quality management knowledge with real-world scenarios. With in-depth healthcare quality management case studies, tools, activities, and discussion questions, the text helps build the competencies needed to succeed in quality management. Written in an easy-to-read style, Part One of the textbook introduces students to the fundamentals of quality management, including history, culture, and different quality management philosophies, such as Lean and Six Sigma. Part One additionally explains the A3 problem-solving template used to follow the Plan-Do-Study-Act (PDSA) or Define, Measure, Analyze, Improve, and Control (DMAIC) cycles, that guides your completion of the problem-solving exercises found in Part Two. The bulk of the textbook includes realistic and engaging case studies featuring common quality management problems encountered in a variety of healthcare settings. The case studies feature engaging scenarios, descriptions, opinions, charts, and data, covering such contemporary topics as provider burnout, artificial intelligence, the opioid overdose epidemic, among many more. Serving as a powerful replacement to more theory-based quality management textbooks, Healthcare Quality Management provides context to challenging situations encountered by any healthcare manager, including the health administrator, nurse, physician, social worker, or allied health professional. KEY FEATURES: 25 Realistic Case Studies–Explore challenging Process Improvement, Patient Experience, Patient Safety, and Performance Improvement quality management scenarios set in various healthcare settings Diverse Author Team–Combines the expertise and knowledge of a health management educator, a Chief Nursing Officer at a large regional hospital, and a health system-based Certified Lean Expert Podcasts–Listen to quality management experts share stories and secrets on how to succeed, work in teams, and apply tools to solve problems Quality Management Tools–Grow your quality management skill set with 25 separate quality management tools and approaches tied to the real-world case studies Competency-Based Education Support–Match case studies to professional competencies, such as analytical skills, community collaboration, and interpersonal relations, using case-to-competency crosswalks for health administration, nursing, medicine, and the interprofessional team Comprehensive Instructor’s Packet–Includes PPTs, extensive Excel data files, an Instructor’s Manual with completed A3 problem-solving solutions for each Case Application Exercise, and more! Student ancillaries–Includes data files and A3 template |
| example of root cause analysis in healthcare: Josie's Story Sorrel King, 2010-09-14 The “wrenching but inspiring” true story of a tragic medical mistake that turned a grieving mother into a national advocate (The Wall Street Journal). Sorrel King was a young mother of four when her eighteen-month-old daughter was badly burned by a faulty water heater in the family’s new home. Taken to the world-renowned Johns Hopkins Hospital, Josie made a remarkable recovery. But as she was preparing to leave, the hospital’s system of communication broke down and Josie was given a fatal shot of methadone, sending her into cardiac arrest. Within forty-eight hours, the King family went from planning a homecoming to planning a funeral. Dizzy with grief, falling into deep depression, and close to ending her marriage, Sorrel slowly pulled herself and her life back together. Accepting Hopkins’ settlement, she and her husband established the Josie King Foundation. They began to implement basic programs in hospitals emphasizing communication between patients, family, and medical staff—programs like Family-Activated Rapid Response Teams, which are now in place in hospitals around the country. Today Sorrel and the work of the foundation have had a tremendous impact on health-care providers, making medical care safer for all of us, and earning Sorrel a well-deserved reputation as one of the leading voices in patient safety. “I cried . . . I cheered” at this account of one woman’s unlikely path from full-time mom to nationally renowned patient advocate (Ann Hood). “Part indictment, part celebration, part catharsis” Josie’s Story is the startling, moving, and inspirational chronicle of how a mother—and her unforgettable daughter—are transforming the face of American medicine (Richmond Times-Dispatch). |
| example of root cause analysis in healthcare: To Err Is Human Institute of Medicine, Committee on Quality of Health Care in America, 2000-03-01 Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€with state and local implicationsâ€for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€which begs the question, How can we learn from our mistakes? Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine |
| example of root cause analysis in healthcare: Culture at Work in Aviation and Medicine Robert L. Helmreich, Ashleigh C. Merritt, 2019-01-15 Published in 1998, culture forms a complex framework of national, organizational, and professional attitudes and values within which groups and individuals function. The reality and strength of culture become salient when we work within a new group and interact with people who have well established norms and values. In this book the authors report the results of their ongoing exploration of the influences of culture in two professions, aviation and medicine. Their focus is on commercial airline pilots and operating room teams. Within these two environments they show the effect of professional, national and organizational cultures of individual attitudes and values and team interaction. |
| example of root cause analysis in healthcare: Fetal & Neonatal Secrets Richard Polin, Alan R. Spitzer, 2013-10-01 Fetal and Neonatal Secrets by Drs. Richard Polin and Alan Spitzer, uses the success formula of the highly popular Secrets Series to offer fast answers to the most essential clinical questions in fetal and neonatal medicine. With its user-friendly Q&A format, practical tips from neonatologists and fetal medicine experts, and Key Points boxes, this portable and easy-to-read medical reference book provides rapid access to the practical knowledge you need to succeed both in practice and on board and recertification exams. Fetal and Neonatal Secrets is a book with an alternative setup that offers answers to a wide spectrum of clinical questions in the field of fetal and neonatal medicine. The book covers both fetal and neonatal medicine, and could be relevant for junior doctors aiming to become obstetricians or pediatricians. Reviewed by: Acta Obstetricia et Gynecologica Scandinavica, January 2015 - Get the evidence-based guidance you need to provide optimal care for your fetal and neonatal patients. - Zero in on key fetal and neonatal information with a question and answer format, bulleted lists, mnemonics, and practical tips from the authors. - Enhance your reference power with a two-color page layout, Key Points boxes, and lists of useful websites. - Review essential material efficiently with the Top 100 Secrets in Fetal and Neonatal Medicine – perfect for last-minute study or self-assessment. - Apply all the latest pediatric advances in clinical fetal neonatology techniques, technology, and pharmacology |
| example of root cause analysis in healthcare: The Lean Healthcare Handbook Thomas Pyzdek, 2021-04-28 The book shows readers exactly how to use Lean tools to design healthcare work that is smooth, efficient, error free and focused on patients and patient outcomes. It includes in-depth discussions of every important Lean tool, including value stream maps, takt time, spaghetti diagrams, workcell design, 5S, SMED, A3, Kanban, Kaizen and many more, all presented in the context of healthcare. For example, the book explains the importance of quick operating room or exam room changeovers and shows the reader specific methods for drastically reducing changeover time. Readers will learn to create healthcare value streams where workflows are based on the pull of customer/patient demand. The book also presents a variety of ways to continue improving after initial Lean successes. Methods for finding the root causes of problems and implementing effective solutions are described and demonstrated. The approach taught here is based on the Toyota Production System, which has been adopted worldwide by healthcare organizations for use in clinical, non-clinical and administrative areas. |
EXAMPLE Definition & Meaning - Merriam-Webster
The meaning of EXAMPLE is one that serves as a pattern to be imitated or not to be imitated. How to use example in a sentence. Synonym Discussion …
EXAMPLE | English meaning - Cambridge Dictionary
EXAMPLE definition: 1. something that is typical of the group of things that it is a member of: 2. a way of helping…. …
EXAMPLE Definition & Meaning | Dictionary.com
one of a number of things, or a part of something, taken to show the character of the whole. This painting is an example of his early work. a pattern …
Example - definition of example by The Free Dictiona…
1. one of a number of things, or a part of something, taken to show the character of the whole. 2. a pattern or model, as of something to be …
Example Definition & Meaning - YourDictionary
To be illustrated or exemplified (by). Wear something simple; for example, a skirt and blouse.
EXAMPLE Definition & Meaning - Merriam-Webster
The meaning of EXAMPLE is one that serves as a pattern to be imitated or not to be imitated. How to use example in a sentence. Synonym Discussion …
EXAMPLE | English meaning - Cambridge Dictionary
EXAMPLE definition: 1. something that is typical of the group of things that it is a member of: 2. a way of helping…. …
EXAMPLE Definition & Meaning | Dictionary.com
one of a number of things, or a part of something, taken to show the character of the whole. This painting is an example of his early work. a pattern …
Example - definition of example by The Free Dictiona…
1. one of a number of things, or a part of something, taken to show the character of the whole. 2. a pattern or model, as of something to be …
Example Definition & Meaning - YourDictionary
To be illustrated or exemplified (by). Wear something simple; for example, a skirt and blouse.
