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Chapter 6 - Cause Analysis

from Section 2 - Quality Improvement Tools

Published online by Cambridge University Press:  27 July 2023

By
Kristina A. Toncray
Edited by
Sally E. Rampersad  and
Cindy B. Katz
Sally E. Rampersad
Affiliation:
University of Washington School of Medicine, Seattle
Cindy B. Katz
Affiliation:
Seattle Children’s Hospital, Washington
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Summary

We all make errors every day. In healthcare, the errors we make can harm our patients. When such an event happens, the institution owes it not only to the patient but also to the staff involved in an event, as well as to future patients who may be similarly harmed, to learn from the event and to prevent similar events from happening again. There are various types of Cause Analysis, or tools used to analyze the causes of certain events. Usually such tools are used to study an undesired outcome, and in healthcare, these are often used to study adverse events. This chapter will describe the process of performing a Root Cause Analysis for serious events, as well as touch upon the concepts of Apparent Cause Analysis for less serious events and Common Cause Analysis to look for themes across events. Failure Mode Effects Analysis (FMEA), related to Cause Analysis, is described separately in Chapter 10.

Keywords

Root Cause AnalysisApparent Cause AnalysisAggregate Root Cause AnalysisSystemic Cause AnalysisCommon Cause Analysis
Type
Chapter
Information
Patient Safety and Quality Improvement in Anesthesiology and Perioperative Medicine , pp. 40 - 48
Publisher: Cambridge University Press
Print publication year: 2023

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References

U.S. Department of Veterans Affairs. VA National Center for Patient Safety, Glossary of Patient Safety Terms; 2015. Available at www.patientsafety.va.gov/professionals/publications/glossary.asp (Accessed 5/6/21).Google Scholar
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The Joint Commission. Patient Safety Topics, Sentinel Event. The RCA2: Improving Root Cause Analyses and Actions to Prevent Harm; 2015. Available at www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/rca_framework_101017.pdf?db=web&hash=B2B439317A20C3D1982F9FBB94E1724B (Accessed 9/13/2020).Google Scholar
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Bogue, TL and Bogue, RL. Unbundling the bundles: Using apparent and systemic cause analysis to prevent health care-associated infection in pediatric intensive care units. Critical Care Nursing Clinics of North America. 2017;29(2):217–231.CrossRefGoogle Scholar
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  • Cause Analysis
  • Edited by Sally E. Rampersad, University of Washington School of Medicine, Seattle, Cindy B. Katz, Seattle Children’s Hospital, Washington
  • Book: Patient Safety and Quality Improvement in Anesthesiology and Perioperative Medicine
  • Online publication: 27 July 2023
  • Chapter DOI: https://doi.org/10.1017/9781108125758.006
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  • Cause Analysis
  • Edited by Sally E. Rampersad, University of Washington School of Medicine, Seattle, Cindy B. Katz, Seattle Children’s Hospital, Washington
  • Book: Patient Safety and Quality Improvement in Anesthesiology and Perioperative Medicine
  • Online publication: 27 July 2023
  • Chapter DOI: https://doi.org/10.1017/9781108125758.006
Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

  • Cause Analysis
  • Edited by Sally E. Rampersad, University of Washington School of Medicine, Seattle, Cindy B. Katz, Seattle Children’s Hospital, Washington
  • Book: Patient Safety and Quality Improvement in Anesthesiology and Perioperative Medicine
  • Online publication: 27 July 2023
  • Chapter DOI: https://doi.org/10.1017/9781108125758.006
Available formats
×