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Chapter 6 - Cause Analysis
from Section 2 - Quality Improvement Tools
- By Kristina A. Toncray
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

Published online:

27 July 2023

Print publication:

25 May 2023, pp 40-48
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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.