Book contents
- Patient Safety and Quality Improvement in Anesthesiology and Perioperative Medicine
- Patient Safety and Quality Improvement in Anesthesiology and Perioperative Medicine
- Copyright page
- Contents
- Figures
- Tables
- Contributors
- Acknowledgments
- Chapter 1 Introduction
- Section 1 Design and Simulation
- Section 2 Quality Improvement Tools
- Chapter 4 Preoccupation with Failure: Daily Management System
- Chapter 5 Lean versus Model for Improvement
- Chapter 6 Cause Analysis
- Section 3 Reporting and Databases
- Section 4 Putting Tools into Practice
- Section 5 People, Behavior, and Communication
- Index
- References
Chapter 6 - Cause Analysis
from Section 2 - Quality Improvement Tools
Published online by Cambridge University Press: 27 July 2023
Book contents
- Patient Safety and Quality Improvement in Anesthesiology and Perioperative Medicine
- Patient Safety and Quality Improvement in Anesthesiology and Perioperative Medicine
- Copyright page
- Contents
- Figures
- Tables
- Contributors
- Acknowledgments
- Chapter 1 Introduction
- Section 1 Design and Simulation
- Section 2 Quality Improvement Tools
- Chapter 4 Preoccupation with Failure: Daily Management System
- Chapter 5 Lean versus Model for Improvement
- Chapter 6 Cause Analysis
- Section 3 Reporting and Databases
- Section 4 Putting Tools into Practice
- Section 5 People, Behavior, and Communication
- Index
- References
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
- Type
- Chapter
- Information
- Publisher: Cambridge University PressPrint publication year: 2023
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
The National Quality Forum. Serious Reportable Events; 2009. Available at www.qualityforum.org/Topics/SREs/Serious_Reportable_Events.aspx (Accessed 9/13/2020).Google Scholar
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
Agency for Healthcare Research and Quality. Patient Safety Primer, Root Cause Analysis; 2019. Available at https://psnet.ahrq.gov/primers/primer/10/root-cause-analysis (Accessed 9/13/2020).Google Scholar
U.S. Department of Veterans Affairs. VA National Center for Patient Safety, Root Cause Analysis; 2018. Available at www.patientsafety.va.gov/professionals/onthejob/rca.asp (Accessed 9/13/2020).Google Scholar
Toyota Motor Asia Pacific. Ask “Why” Five Times about Every Matter; 2014–2016. Available at www.toyota-myanmar.com/about-toyota/toyota-traditions/quality/ask-why-five-times-about-every-matter#:~:text=%E2%80%9CAsk%20'why'%20five%20times,Why%20did%20the%20robot%20stop%3F%E2%80%9D (Accessed 9/13/2020).Google Scholar
Institute for Healthcare Improvement. Ask “Why” Five Times to Get to the Root Cause; 2020. Available at www.ihi.org/resources/Pages/ImprovementStories/AskWhyFiveTimestoGettotheRootCause.aspx/ (Accessed 9/13/2020).Google Scholar
Institute for Healthcare Improvement. RCA2: Improving Root Cause Analyses and Actions to Prevent Harm; 2016. Available at www.ihi.org/resources/Pages/Tools/RCA2-Improving-Root-Cause-Analyses-and-Actions-to-Prevent-Harm.aspx (Accessed 7/10/2022).Google Scholar
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
Mallett, R, Conroy, M, Saslaw, LZ, et al. Preventing wrong site, procedure, and patient events using a common cause analysis. American Journal of Medical Quality. 2012;27:21–29.Google Scholar
Browne, AM, Mullen, R, Teets, J, et al. Common cause analysis: Focus on institutional change. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment).Google ScholarGoogle Scholar
Clapper, C, Crea, K. Common Cause Analysis. Patient Safety & Quality Healthcare; 2010. Available at www.psqh.com/analysis/common-cause-analysis/ (Accessed 9/13/2020).Google Scholar
Neily, J, et al. Using aggregate root cause analysis to improve patient safety. The Joint Commission Journal on Quality and Safety. 2003;29(8):434–439.CrossRefGoogle Scholar