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Implementation of Enhanced Root Cause Analysis Process to Improve Patient Safety

Implementation of Enhanced Root Cause Analysis Process to Improve Patient Safety
Author: Amy C. Plotts
Publisher:
Total Pages: 0
Release: 2022
Genre: Patients
ISBN:

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Background: Root cause analysis (RCA) is a tool for identifying prevention strategies that use a multidisciplinary team approach to analyze healthcare-related adverse events and near misses. A key to improving patient safety and providing quality care is a thorough RCA process that identifies, reports, reviews, and addresses problems related to adverse events and near misses. Problem: The stakeholders want to improve turnaround time for RCA completion without compromising the quality of the process to improve patient safety and quality outcomes. Improving the RCA process is a local practice problem in the suburban academic medical setting based on data from senior directors of patient safety, risk management, and quality. Methods: A revised RCA workflow process was designed for this quality improvement project using the Plan-Do-Study-Act (PDSA) cycle. The project consisted of implementing an enhanced RCA process to improve the timeliness from RCA declaration to analysis completion to ensure that factors leading to significant events are addressed quickly. The mean time for pre- and post-implementation phases were calculated to evaluate the effect of an enhanced process to improve the timeliness of RCA completion. Results: Comparing pre-intervention and post-intervention mean time for RCA declaration to completion was 79.2 to 31.7 days. A t-test to compare the means of RCA days to completion using a level of significance of 0.05 identified a statistical difference between pre-and post-intervention groups. Conclusions: The new RCA process demonstrated a correlation between the intervention and timeliness of RCA completion.


Root Cause Analysis (RCA) for the Improvement of Healthcare Systems and Patient Safety

Root Cause Analysis (RCA) for the Improvement of Healthcare Systems and Patient Safety
Author: David Allison, CPPS
Publisher: CRC Press
Total Pages: 129
Release: 2021-08-24
Genre: Technology & Engineering
ISBN: 1000430065

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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.


Patient Safety in Dialysis Access

Patient Safety in Dialysis Access
Author: M.K. Widmer
Publisher: Karger Medical and Scientific Publishers
Total Pages: 282
Release: 2015-02-11
Genre: Medical
ISBN: 3318027065

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Not only are dialysis access creation and maintenance prone to complications, but patients suffering from end-stage renal disease and its comorbidities generally have a high risk of adverse events during their continuous treatment. Preventive strategies are key to avoid harm and to improve the outcome of the treatment of the growing number of patients with chronic kidney failure, especially as doctors and nurses are not always aware of the consequences of unsafe behavior. This publication is intended for health care professionals – nurses as well as doctors – and aims to raise the awareness of patient safety aspects, combining medical education with evidence-based medicine. After a general overview of the topic, an international panel of authors provides a diversified insight into important concepts and technical tricks essential to create and maintain a functional dialysis access.


Patient Safety

Patient Safety
Author: Abha Agrawal
Publisher: Springer Science & Business Media
Total Pages: 412
Release: 2013-10-04
Genre: Medical
ISBN: 1461474191

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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.


Making Healthcare Safe

Making Healthcare Safe
Author: Lucian L. Leape
Publisher: Springer Nature
Total Pages: 450
Release: 2021-05-28
Genre: Medical
ISBN: 3030711234

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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.


Patient Safety

Patient Safety
Author: Robert J. Latino
Publisher: CRC Press
Total Pages: 224
Release: 2008-10-14
Genre: Business & Economics
ISBN: 1420087282

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Are you ready and willing to get to the root causes of problems? As Medicare, Medicaid, and major insurance companies increasingly deny payment for never events, it has become imperative that hospitals and doctors develop new ways to prevent these avoidable catastrophes from recurring. Proactive tools such as root cause analysis (RCA), basic failur


Resident Duty Hours

Resident Duty Hours
Author: Institute of Medicine
Publisher: National Academies Press
Total Pages: 427
Release: 2009-04-27
Genre: Medical
ISBN: 0309131529

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Medical residents in hospitals are often required to be on duty for long hours. In 2003 the organization overseeing graduate medical education adopted common program requirements to restrict resident workweeks, including limits to an average of 80 hours over 4 weeks and the longest consecutive period of work to 30 hours in order to protect patients and residents from unsafe conditions resulting from excessive fatigue. Resident Duty Hours provides a timely examination of how those requirements were implemented and their impact on safety, education, and the training institutions. An in-depth review of the evidence on sleep and human performance indicated a need to increase opportunities for sleep during residency training to prevent acute and chronic sleep deprivation and minimize the risk of fatigue-related errors. In addition to recommending opportunities for on-duty sleep during long duty periods and breaks for sleep of appropriate lengths between work periods, the committee also recommends enhancements of supervision, appropriate workload, and changes in the work environment to improve conditions for safety and learning. All residents, medical educators, those involved with academic training institutions, specialty societies, professional groups, and consumer/patient safety organizations will find this book useful to advocate for an improved culture of safety.