-
1
-
-
0003413171
-
-
Institute of Medicine:, Washington, DC: National Academy Press
-
Institute of Medicine: To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 1999.
-
(1999)
To Err Is Human: Building a Safer Health System
-
-
-
2
-
-
34547611678
-
-
The Joint Commission:, Jul. 2007, last accessed May 19, 2007
-
The Joint Commission: Sentinel Event Policy and Procedures. Jul. 2007. http://www.jointcommission.org/SentinelEvents/PolicyandProcedures/ (last accessed May 19, 2007).
-
Sentinel Event Policy and Procedures
-
-
-
3
-
-
0036782125
-
The Veterans Affairs root cause analysis system in action
-
Oct
-
Bagian J.P., et al.: The Veterans Affairs root cause analysis system in action. Jt Comm J Qual Improv 28:531-545, Oct. 2002.
-
(2002)
Jt Comm J Qual Improv
, vol.28
, pp. 531-545
-
-
Bagian, J.P.1
-
4
-
-
0036884704
-
John M. Eisenberg Patient Safety Awards. System innovation: Veterans Health Administration National Center for Patient Safety
-
Dec
-
Heget J.R., et al.: John M. Eisenberg Patient Safety Awards. System innovation: Veterans Health Administration National Center for Patient Safety. Jt Comm J Qual Improv 28:660-665, Dec. 2002.
-
(2002)
Jt Comm J Qual Improv
, vol.28
, pp. 660-665
-
-
Heget, J.R.1
-
5
-
-
2342433542
-
Achieving a safer health service: Part 3. Investigating root causes and formulating solutions
-
Mar
-
Woodward S.: Achieving a safer health service: Part 3. Investigating root causes and formulating solutions. Prof Nurse 19:390-394, Mar. 2004.
-
(2004)
Prof Nurse
, vol.19
, pp. 390-394
-
-
Woodward, S.1
-
6
-
-
34548082808
-
Understanding harm of patients during hospitalization. Root cause analysis legislation - What is it and why is it needed?
-
Jun
-
Wakefield J.: Understanding harm of patients during hospitalization. Root cause analysis legislation - What is it and why is it needed? Qld Nurse 26:22, Jun. 2007.
-
(2007)
Qld Nurse
, vol.26
, pp. 22
-
-
Wakefield, J.1
-
7
-
-
33845896777
-
Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme
-
Dec
-
Braithwaite J., et al.: Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme. Qual Saf Health Care 15:393-399, Dec. 2006.
-
(2006)
Qual Saf Health Care
, vol.15
, pp. 393-399
-
-
Braithwaite, J.1
-
8
-
-
0035486819
-
Developing and deploying a patient safety program in a large health care delivery system: You can't fix what you don't know about
-
Oct
-
Bagian J.P., et al.: Developing and deploying a patient safety program in a large health care delivery system: You can't fix what you don't know about. Jt Comm J Qual Improv 27:522-532, Oct. 2001.
-
(2001)
Jt Comm J Qual Improv
, vol.27
, pp. 522-532
-
-
Bagian, J.P.1
-
9
-
-
0033196773
-
Sentinel events, root cause analysis, and proactive risk reduction
-
Fall
-
Croteau R.: Sentinel events, root cause analysis, and proactive risk reduction. Ambul Outreach pp. 19-22, Fall 1999.
-
(1999)
Ambul Outreach
, pp. 19-22
-
-
Croteau, R.1
-
10
-
-
39049137453
-
Effectiveness and efficiency of root cause analysis in medicine
-
Feb. 13
-
Wu A.W., Lipshutz A.K.M., Pronovost P.J.: Effectiveness and efficiency of root cause analysis in medicine. JAMA 299:685-687, Feb. 13, 2008.
-
(2008)
JAMA
, vol.299
, pp. 685-687
-
-
Wu, A.W.1
Lipshutz, A.K.M.2
Pronovost, P.J.3
-
11
-
-
25644434375
-
Decreasing mortality for patients undergoing hip fracture repair surgery
-
Jun
-
McGinn T., et al.: Decreasing mortality for patients undergoing hip fracture repair surgery. Jt Comm J Qual Patient Saf 31:304-307, Jun. 2005.
-
(2005)
Jt Comm J Qual Patient Saf
, vol.31
, pp. 304-307
-
-
McGinn, T.1
-
12
-
-
27144533185
-
Using root cause analysis to improve survival in a liver transplant program
-
Nov
-
Perkins J.D., et al.: Using root cause analysis to improve survival in a liver transplant program. J Surg Res 129:6-16, Nov. 2005.
-
(2005)
J Surg Res
, vol.129
, pp. 6-16
-
-
Perkins, J.D.1
-
13
-
-
0034302388
-
Systematic root cause analysis of adverse drug events in a tertiary referral hospital
-
Oct
-
Rex J.H., et al.: Systematic root cause analysis of adverse drug events in a tertiary referral hospital. Jt Comm J Qual Improv 26:563-575, Oct. 2000.
-
(2000)
Jt Comm J Qual Improv
, vol.26
, pp. 563-575
-
-
Rex, J.H.1
-
14
-
-
33646909208
-
Efficiency of a semiautomated coding and review process for notification of critical findings in diagnostic imaging
-
Apr
-
Choksi V.R., et al.: Efficiency of a semiautomated coding and review process for notification of critical findings in diagnostic imaging. AJR Am J Roentgenol 186:933-936, Apr. 2006.
-
(2006)
AJR Am J Roentgenol
, vol.186
, pp. 933-936
-
-
Choksi, V.R.1
-
15
-
-
21244449874
-
Learning to improve safety: False-positive pathology report results in wrongful surgery
-
Mar
-
Piotrowski, et al.: Learning to improve safety: False-positive pathology report results in wrongful surgery. Jt Comm J Qual Patient Saf 31:123-131, Mar. 2005.
-
(2005)
Jt Comm J Qual Patient Saf
, vol.3
, Issue.1
, pp. 123-131
-
-
Piotrowski1
-
16
-
-
3242666728
-
Patient safety in the ambulatory setting. A clinician-based approach
-
Jul
-
Plews-Ogan M.L., et al.: Patient safety in the ambulatory setting. A clinician-based approach. J Gen Intern Med 19:719-725, Jul. 2004.
-
(2004)
J Gen Intern Med
, vol.19
, pp. 719-725
-
-
Plews-Ogan, M.L.1
-
19
-
-
33750699010
-
Actions and implementation strategies to reduce suicidal events in the Veterans Health Administration
-
Mar
-
Mills P.D., et al.: Actions and implementation strategies to reduce suicidal events in the Veterans Health Administration. Jt Comm J Qual Patient Saf 32:130-141, Mar. 2006.
-
(2006)
Jt Comm J Qual Patient Saf
, vol.32
, pp. 130-141
-
-
Mills, P.D.1
-
20
-
-
33644641858
-
Implementing root cause analysis in an area health service: Views of the participants
-
Nov
-
Middleton S., Walker C., Chestet R.: Implementing root cause analysis in an area health service: Views of the participants. Aust Health Rev 29:422-428, Nov. 2005.
-
(2005)
Aust Health Rev
, vol.29
, pp. 422-428
-
-
Middleton, S.1
Walker, C.2
Chestet, R.3
-
21
-
-
84889425388
-
-
Department of Veterans Affairs, National Center for Patient Safety:, Recommended Hierarchy of Actions, last accessed May 19
-
Department of Veterans Affairs, National Center for Patient Safety: Root Cause Analysis Tools. (Recommended Hierarchy of Actions). http://www.va.gov/ncps/CogAids/RCA/index.html (last accessed May 19, 2007).
-
(2007)
Root Cause Analysis Tools
-
-
-
22
-
-
0347586852
-
Organization of event reporting data for sense making and system improvement
-
Dec
-
Kaplan H.S., Fastman B.R.: Organization of event reporting data for sense making and system improvement. Qual Saf Health Care 12(suppl. 2): ii68-ii72, Dec. 2003.
-
(2003)
Qual Saf Health Care
, vol.12
, Issue.SUPPL. 2
-
-
Kaplan, H.S.1
Fastman, B.R.2
-
23
-
-
34250822228
-
Learning from unexpected events: A root cause analysis training program
-
Sep.-Oct
-
Sweitzer S.C., Silver M.P.: Learning from unexpected events: A root cause analysis training program. J Healthc Qual 27:11-19, Sep.-Oct. 2005.
-
(2005)
J Healthc Qual
, vol.27
, pp. 11-19
-
-
Sweitzer, S.C.1
Silver, M.P.2
-
24
-
-
32644445357
-
Turning the medical gaze in upon itself: Root cause analysis and the investigation of clinical error
-
Apr
-
Iedema R.A., et al.: Turning the medical gaze in upon itself: Root cause analysis and the investigation of clinical error. Soc Sci Med 62:1605-1615, Apr. 2006.
-
(2006)
Soc Sci Med
, vol.62
, pp. 1605-1615
-
-
Iedema, R.A.1
-
25
-
-
2342585431
-
Hindsight not equal to foresight: The effect of outcome knowledge on judgment under uncertainty. 1975
-
discussion 301-302, Aug
-
Fischhoff B.: Hindsight not equal to foresight: The effect of outcome knowledge on judgment under uncertainty. 1975. Qual Saf Health Care 12:304-311; discussion 301-302, Aug. 2003.
-
(2003)
Qual Saf Health Care
, vol.12
, pp. 304-311
-
-
Fischhoff, B.1
-
26
-
-
0038807440
-
Errors today and errors tomorrow
-
Jun. 19
-
Berwick D.M.: Errors today and errors tomorrow. N Engl J Med 348:2570-2572, Jun. 19, 2003.
-
(2003)
N Engl J Med
, vol.348
, pp. 2570-2572
-
-
Berwick, D.M.1
-
27
-
-
0036752770
-
Lessons learned from non-medical industries: Root cause analysis as culture change at a chemical plant
-
Sep
-
Carroll J.S., Rudolph J.W., Hatakenaka S.: Lessons learned from non-medical industries: Root cause analysis as culture change at a chemical plant. Qual Saf Health Care 11:266-269, Sep. 2002.
-
(2002)
Qual Saf Health Care
, vol.11
, pp. 266-269
-
-
Carroll, J.S.1
Rudolph, J.W.2
Hatakenaka, S.3
-
29
-
-
0348194674
-
Corrective and preventive action
-
Oct
-
Motschman T.L., Moore S.B.: Corrective and preventive action. Transfus Sci 21:163-178, Oct. 1999.
-
(1999)
Transfus Sci
, vol.21
, pp. 163-178
-
-
Motschman, T.L.1
Moore, S.B.2
-
30
-
-
38549099961
-
Root cause analysis: A framework for tool selection
-
Doggett A.M.: Root cause analysis: A framework for tool selection. The Quality Management Journal 12(4):34-45, 2005.
-
(2005)
The Quality Management Journal
, vol.12
, Issue.4
, pp. 34-45
-
-
Doggett, A.M.1
-
31
-
-
85062104396
-
The investigation and analysis of critical incidents and adverse events in healthcare
-
May
-
Woloshynowych M., et al.: The investigation and analysis of critical incidents and adverse events in healthcare. Health Technol Assess 9:1-158, May 2005.
-
(2005)
Health Technol Assess
, vol.9
, pp. 1-158
-
-
Woloshynowych, M.1
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