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| examples 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. |
| examples 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 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. |
| examples 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. |
| examples 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. |
| examples 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. |
| examples 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. |
| examples 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. |
| examples 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. |
| examples 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 |
| examples 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. |
| examples 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. |
| examples 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. |
| examples of root cause analysis in healthcare: Patient Safety Abha Agrawal, 2013-10-04 Despite the evolution and growing awareness of patient safety, many medical professionals are not a part of this important conversation. Clinicians often believe they are too busy taking care of patients to adopt and implement patient safety initiatives and that acknowledging medical errors is an affront to their skills. Patient Safety provides clinicians with a better understanding of the prevalence, causes and solutions for medical errors; bringing best practice principles to the bedside. Written by experts from a variety of backgrounds, each chapter features an analysis of clinical cases based on the Root Cause Analysis (RCA) methodology, along with case-based discussions on various patient safety topics. The systems and processes outlined in the book are general and broadly applicable to institutions of all sizes and structures. The core ethic of medical professionals is to “do no harm”. Patient Safety is a comprehensive resource for physicians, nurses and students, as well as healthcare leaders and administrators for identifying, solving and preventing medical error. |
| examples 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. |
| examples 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. |
| examples 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. |
| examples 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. |
| examples 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. |
| examples 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. |
| examples 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. |
| examples 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. |
| examples 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. |
| examples of root cause analysis in healthcare: Root Cause Analysis in Health Care , 2017 Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse Events will take readers step by step through the process of conducting RCA in their organizations. It will also offer strategies and suggestions for implementing FMEA. Featuring a newly streamlined, approachable design, this 7th edition of our best-selling Root Cause Analysis in Health Care will guide health care organizations through the Joint Commission requirements, outlining steps to prevent sentinel events such as medication errors, patient suicide, wrong-site surgery, patient elopement, and more. Refreshed tools and examples will help organizations collect the data they need and demonstrate how to use that data to learn from previous experience. |
| examples of root cause analysis in healthcare: Improving Healthcare Quality in Europe Characteristics, Effectiveness and Implementation of Different Strategies OECD, World Health Organization, 2019-10-17 This volume, developed by the Observatory together with OECD, provides an overall conceptual framework for understanding and applying strategies aimed at improving quality of care. Crucially, it summarizes available evidence on different quality strategies and provides recommendations for their implementation. This book is intended to help policy-makers to understand concepts of quality and to support them to evaluate single strategies and combinations of strategies. |
| examples 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. |
| examples of root cause analysis in healthcare: Keeping Patients Safe Institute of Medicine, Board on Health Care Services, Committee on the Work Environment for Nurses and Patient Safety, 2004-03-27 Building on the revolutionary Institute of Medicine reports To Err is Human and Crossing the Quality Chasm, Keeping Patients Safe lays out guidelines for improving patient safety by changing nurses' working conditions and demands. Licensed nurses and unlicensed nursing assistants are critical participants in our national effort to protect patients from health care errors. The nature of the activities nurses typically perform †monitoring patients, educating home caretakers, performing treatments, and rescuing patients who are in crisis †provides an indispensable resource in detecting and remedying error-producing defects in the U.S. health care system. During the past two decades, substantial changes have been made in the organization and delivery of health care †and consequently in the job description and work environment of nurses. As patients are increasingly cared for as outpatients, nurses in hospitals and nursing homes deal with greater severity of illness. Problems in management practices, employee deployment, work and workspace design, and the basic safety culture of health care organizations place patients at further risk. This newest edition in the groundbreaking Institute of Medicine Quality Chasm series discusses the key aspects of the work environment for nurses and reviews the potential improvements in working conditions that are likely to have an impact on patient safety. |
| examples of root cause analysis in healthcare: Health Care Comes Home National Research Council, Division of Behavioral and Social Sciences and Education, Board on Human-Systems Integration, Committee on the Role of Human Factors in Home Health Care, 2011-06-22 In the United States, health care devices, technologies, and practices are rapidly moving into the home. The factors driving this migration include the costs of health care, the growing numbers of older adults, the increasing prevalence of chronic conditions and diseases and improved survival rates for people with those conditions and diseases, and a wide range of technological innovations. The health care that results varies considerably in its safety, effectiveness, and efficiency, as well as in its quality and cost. Health Care Comes Home reviews the state of current knowledge and practice about many aspects of health care in residential settings and explores the short- and long-term effects of emerging trends and technologies. By evaluating existing systems, the book identifies design problems and imbalances between technological system demands and the capabilities of users. Health Care Comes Home recommends critical steps to improve health care in the home. The book's recommendations cover the regulation of health care technologies, proper training and preparation for people who provide in-home care, and how existing housing can be modified and new accessible housing can be better designed for residential health care. The book also identifies knowledge gaps in the field and how these can be addressed through research and development initiatives. Health Care Comes Home lays the foundation for the integration of human health factors with the design and implementation of home health care devices, technologies, and practices. The book describes ways in which the Agency for Healthcare Research and Quality (AHRQ), the U.S. Food and Drug Administration (FDA), and federal housing agencies can collaborate to improve the quality of health care at home. It is also a valuable resource for residential health care providers and caregivers. |
| examples 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. |
| examples of root cause analysis in healthcare: Patient Safety and Quality Ronda Hughes, 2008 Nurses play a vital role in improving the safety and quality of patient car -- not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes. To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality -- Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043). - online AHRQ blurb, http://www.ahrq.gov/qual/nurseshdbk/ |
| examples 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. |
| examples 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. |
| examples 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. |
| examples of root cause analysis in healthcare: Patient Safety Handbook Barbara J. Youngberg, 2013 Examines the newest scientific advances in the science of safety. |
| examples of root cause analysis in healthcare: The Fragmentation of U.S. Health Care Einer Elhauge, 2010 Why is the American health care system so fragmented in the care it gives patients? This title approaches this question and more with a highly interdisciplinary approach. The articles included in the work address legal and regulatory issues, including laws that mandate separate payments for each provider. |
| examples 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 |
| examples 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). |
| examples of root cause analysis in healthcare: Root Cause Analysis in Health Care , 2020-04 |
| examples of root cause analysis in healthcare: TapRooT Mark Paradies, Linda Unger, 2000 |
| examples of root cause analysis in healthcare: Applied Human Factors in Medical Device Design Mary Beth Privitera, 2019-06-15 Applied Human Factors in Medical Device Design describes the contents of a human factors toolbox with in-depth descriptions of both empirical and analytical methodologies. The book begins with an overview of the design control process, integrating human factors as directed by AAMI TIR 59 and experienced practice. It then explains each method, describing why each method is important, its potential impact, when it's ideal to use, and related challenges. Also discussed are other barriers, such as communication breakdowns between users and design teams. This book is an excellent reference for professionals working in human factors, design, engineering, marketing and regulation. - Focuses on meeting agency requirements as it pertains to the application of human factors in the medical device development process in both the US and the European Union (EU) - Explains technology development and the application of human factors throughout the development process - Covers FDA and MHRA regulations - Includes case examples with each method |
| examples 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 |
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Examples - Apache ECharts
Examples; Resources. Spread Sheet Tool; Theme Builder; Cheat Sheet; More Resources; Community. Events; Committers; Mailing List; How to Contribute; Dependencies; Code Standard; …
Apache ECharts
ECharts: A Declarative Framework for Rapid Construction of Web-based Visualization. 如果您在科研项目、产品、学术论文、技术报告、新闻报告、教育、专利以及其他相关活动中使用了 Apache …
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Examples; Resources. Spread Sheet Tool; Theme Builder; Cheat Sheet; More Resources; Community. Events; Committers; Mailing List; How to Contribute; Dependencies; Code Standard; …
Examples - Apache ECharts
Apache ECharts，一款基于JavaScript的数据可视化图表库，提供直观，生动，可交互，可个性化定制的数据可视化图表。
Examples - Apache ECharts
Examples; Resources. Spread Sheet Tool; Theme Builder; Cheat Sheet; More Resources; Community. Events; Committers; Mailing List; How to Contribute; Dependencies; Code …
Examples - Apache ECharts
Examples; Resources. Spread Sheet Tool; Theme Builder; Cheat Sheet; More Resources; Community. Events; Committers; Mailing List; How to Contribute; Dependencies; Code …
Apache ECharts
ECharts: A Declarative Framework for Rapid Construction of Web-based Visualization. 如果您在科研项目、产品、学术论文、技术报告、新闻报告、教育、专利以及其他相关活动中使用了 …
Events - Apache ECharts
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