메뉴 건너뛰기




Volumn 37, Issue 1, 2010, Pages 141-165

Random safety auditing, root cause analysis, failure mode and effects analysis

Author keywords

Failure mode and effects analysis; Random safety auditing; Root cause analysis

Indexed keywords

CHILD HEALTH CARE; CHILDHOOD MORTALITY; ECONOMIC EVALUATION; HEALTH CARE DELIVERY; HEALTH CARE POLICY; HEALTH CARE PRACTICE; HEALTH CARE QUALITY; HUMAN; INTENSIVE CARE UNIT; MEDICAL AUDIT; MEDICAL ERROR; MORBIDITY; NEWBORN INTENSIVE CARE; PATIENT SAFETY; PRACTICE GUIDELINE; PRIORITY JOURNAL; PROCESS MONITORING; REVIEW; ROOT CAUSE ANALYSIS; SYSTEM ANALYSIS; TEAM BUILDING; TOTAL QUALITY MANAGEMENT; VOLUNTARY REPORTING;

EID: 77951008280     PISSN: 00955108     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.clp.2010.01.008     Document Type: Review
Times cited : (30)

References (56)
  • 2
    • 0003525850 scopus 로고    scopus 로고
    • Institute of Medicine (US).Committee on Quality of Health Care in America, National Academy Press, Washington, DC
    • Institute of Medicine (US).Committee on Quality of Health Care in America Crossing the quality chasm: a new health system for the 21st century 2001, National Academy Press, Washington, DC.
    • (2001) Crossing the quality chasm: a new health system for the 21st century
  • 3
    • 1242267687 scopus 로고    scopus 로고
    • Institute of Medicine (US).Committee on the Work Environment for Nurses and Patient Safety, Page A, National Academies Press, Washington, DC
    • Institute of Medicine (US).Committee on the Work Environment for Nurses and Patient Safety Keeping patients safe: transforming the work environment of nurses 2004, Page A, National Academies Press, Washington, DC.
    • (2004) Keeping patients safe: transforming the work environment of nurses
  • 4
    • 84987994885 scopus 로고    scopus 로고
    • Institute of Medicine (US).Committee on Redesigning Health Insurance Performance Measures Payment and Performance Improvement Programs, National Academies Press, Washington, DC
    • Institute of Medicine (US).Committee on Redesigning Health Insurance Performance Measures Payment and Performance Improvement Programs Performance measurement: accelerating improvement 2006, National Academies Press, Washington, DC.
    • (2006) Performance measurement: accelerating improvement
  • 5
    • 0025924692 scopus 로고
    • Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical practice study I
    • Brennan T.A., Leape L.L., Laird N.M., et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical practice study I. N Engl J Med 1991, 324(6):370-376.
    • (1991) N Engl J Med , vol.324 , Issue.6 , pp. 370-376
    • Brennan, T.A.1    Leape, L.L.2    Laird, N.M.3
  • 6
    • 0026022279 scopus 로고
    • The nature of adverse events in hospitalized patients. Results of the Harvard Medical practice study II
    • Leape L.L., Brennan T.A., Laird N., et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical practice study II. N Engl J Med 1991, 324(6):377-384.
    • (1991) N Engl J Med , vol.324 , Issue.6 , pp. 377-384
    • Leape, L.L.1    Brennan, T.A.2    Laird, N.3
  • 7
    • 0030591365 scopus 로고    scopus 로고
    • Quality in Australian health care study
    • Wilson R.M., Runciman W.B., Gibberd R.W., et al. Quality in Australian health care study. Med J Aust 1996, 164(12):754.
    • (1996) Med J Aust , vol.164 , Issue.12 , pp. 754
    • Wilson, R.M.1    Runciman, W.B.2    Gibberd, R.W.3
  • 8
    • 0035799063 scopus 로고    scopus 로고
    • Adverse events in British hospitals: preliminary retrospective record review
    • Vincent C., Neale G., Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001, 322(7285):517-519.
    • (2001) BMJ , vol.322 , Issue.7285 , pp. 517-519
    • Vincent, C.1    Neale, G.2    Woloshynowych, M.3
  • 9
    • 2942571128 scopus 로고    scopus 로고
    • The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada
    • Baker G.R., Norton P.G., Flintoft V., et al. The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. CMAJ 2004, 170(11):1678-1686.
    • (2004) CMAJ , vol.170 , Issue.11 , pp. 1678-1686
    • Baker, G.R.1    Norton, P.G.2    Flintoft, V.3
  • 10
    • 0031023762 scopus 로고    scopus 로고
    • An alternative strategy for studying adverse events in medical care
    • Andrews L.B., Stocking C., Krizek T., et al. An alternative strategy for studying adverse events in medical care. Lancet 1997, 349(9048):309-313.
    • (1997) Lancet , vol.349 , Issue.9048 , pp. 309-313
    • Andrews, L.B.1    Stocking, C.2    Krizek, T.3
  • 11
    • 0035946697 scopus 로고    scopus 로고
    • Medication errors and adverse drug events in pediatric inpatients
    • Kaushal R., Bates D.W., Landrigan C., et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001, 285(16):2114-2120.
    • (2001) JAMA , vol.285 , Issue.16 , pp. 2114-2120
    • Kaushal, R.1    Bates, D.W.2    Landrigan, C.3
  • 12
    • 23644453746 scopus 로고    scopus 로고
    • Real time patient safety audits: improving safety every day
    • Ursprung R., Gray J.E., Edwards W.H., et al. Real time patient safety audits: improving safety every day. Qual Saf Health Care 2005, 14(4):284-289.
    • (2005) Qual Saf Health Care , vol.14 , Issue.4 , pp. 284-289
    • Ursprung, R.1    Gray, J.E.2    Edwards, W.H.3
  • 13
    • 33644839395 scopus 로고    scopus 로고
    • Patient misidentification in the neonatal intensive care unit: quantification of risk
    • Gray J.E., Suresh G., Ursprung R., et al. Patient misidentification in the neonatal intensive care unit: quantification of risk. Pediatrics 2006, 117(1):e43-e47.
    • (2006) Pediatrics , vol.117 , Issue.1
    • Gray, J.E.1    Suresh, G.2    Ursprung, R.3
  • 14
    • 8144227890 scopus 로고    scopus 로고
    • Reducing medication errors in the neonatal intensive care unit
    • Simpson J.H., Lynch R., Grant J., et al. Reducing medication errors in the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed 2004, 89(6):F480-F482.
    • (2004) Arch Dis Child Fetal Neonatal Ed , vol.89 , Issue.6
    • Simpson, J.H.1    Lynch, R.2    Grant, J.3
  • 15
    • 2542538358 scopus 로고    scopus 로고
    • Voluntary anonymous reporting of medical errors for neonatal intensive care
    • Suresh G., Horbar J.D., Plsek P., et al. Voluntary anonymous reporting of medical errors for neonatal intensive care. Pediatrics 2004, 113(6):1609-1618.
    • (2004) Pediatrics , vol.113 , Issue.6 , pp. 1609-1618
    • Suresh, G.1    Horbar, J.D.2    Plsek, P.3
  • 16
    • 0029384423 scopus 로고
    • The incident reporting system does not detect adverse drug events: a problem for quality improvement
    • Cullen D.J., Bates D.W., Small S.D., et al. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv 1995, 21(10):541-548.
    • (1995) Jt Comm J Qual Improv , vol.21 , Issue.10 , pp. 541-548
    • Cullen, D.J.1    Bates, D.W.2    Small, S.D.3
  • 17
    • 0031920237 scopus 로고    scopus 로고
    • Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report
    • Jha A.K., Kuperman G.J., Teich J.M., et al. Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report. J Am Med Inform Assoc 1998, 5(3):305-314.
    • (1998) J Am Med Inform Assoc , vol.5 , Issue.3 , pp. 305-314
    • Jha, A.K.1    Kuperman, G.J.2    Teich, J.M.3
  • 18
    • 0025719244 scopus 로고
    • Computerized surveillance of adverse drug events in hospital patients
    • Classen D.C., Pestotnik S.L., Evans R.S., et al. Computerized surveillance of adverse drug events in hospital patients. JAMA 1991, 266(20):2847-2851.
    • (1991) JAMA , vol.266 , Issue.20 , pp. 2847-2851
    • Classen, D.C.1    Pestotnik, S.L.2    Evans, R.S.3
  • 19
    • 0037699987 scopus 로고    scopus 로고
    • Adverse drug event trigger tool: a practical methodology for measuring medication related harm
    • Rozich J.D., Haraden C.R., Resar R.K. Adverse drug event trigger tool: a practical methodology for measuring medication related harm. Qual Saf Health Care 2003, 12(3):194-200.
    • (2003) Qual Saf Health Care , vol.12 , Issue.3 , pp. 194-200
    • Rozich, J.D.1    Haraden, C.R.2    Resar, R.K.3
  • 20
    • 0038315446 scopus 로고    scopus 로고
    • Patient safety events during pediatric hospitalizations
    • Miller M.R., Elixhauser A., Zhan C. Patient safety events during pediatric hospitalizations. Pediatrics 2003, 111(6 Pt 1):1358-1366.
    • (2003) Pediatrics , vol.111 , Issue.6 PART 1 , pp. 1358-1366
    • Miller, M.R.1    Elixhauser, A.2    Zhan, C.3
  • 21
    • 2542599293 scopus 로고    scopus 로고
    • Pediatric patient safety in hospitals: a national picture in 2000
    • Miller M.R., Zhan C. Pediatric patient safety in hospitals: a national picture in 2000. Pediatrics 2004, 113(6):1741-1746.
    • (2004) Pediatrics , vol.113 , Issue.6 , pp. 1741-1746
    • Miller, M.R.1    Zhan, C.2
  • 22
    • 33750094473 scopus 로고    scopus 로고
    • Adverse events in the neonatal intensive care unit: development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs
    • Sharek P.J., Horbar J.D., Mason W., et al. Adverse events in the neonatal intensive care unit: development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs. Pediatrics 2006, 118(4):1332-1340.
    • (2006) Pediatrics , vol.118 , Issue.4 , pp. 1332-1340
    • Sharek, P.J.1    Horbar, J.D.2    Mason, W.3
  • 23
    • 0004122234 scopus 로고    scopus 로고
    • United States.Agency for Healthcare Research and Quality University of California San Francisco-Stanford Evidence-Based Practice Center, Agency for Healthcare Research and Quality, U.S. Dept. of Health and Human Services, Rockville (MD)
    • United States.Agency for Healthcare Research and Quality, University of California San Francisco-Stanford Evidence-Based Practice Center Making health care safer: a critical analysis of patient safety practices 2001, Agency for Healthcare Research and Quality, U.S. Dept. of Health and Human Services, Rockville (MD).
    • (2001) Making health care safer: a critical analysis of patient safety practices
  • 24
    • 0036617663 scopus 로고    scopus 로고
    • The safety checklist program: creating a culture of safety in intensive care units
    • Piotrowski M.M., Hinshaw D.B. The safety checklist program: creating a culture of safety in intensive care units. Jt Comm J Qual Improv 2002, 28(6):306-315.
    • (2002) Jt Comm J Qual Improv , vol.28 , Issue.6 , pp. 306-315
    • Piotrowski, M.M.1    Hinshaw, D.B.2
  • 25
    • 0031684045 scopus 로고    scopus 로고
    • Revised checklist for anaesthetic machines
    • Kendell J., Barthram C. Revised checklist for anaesthetic machines. Anaesthesia 1998, 53(9):887-890.
    • (1998) Anaesthesia , vol.53 , Issue.9 , pp. 887-890
    • Kendell, J.1    Barthram, C.2
  • 26
    • 77950976956 scopus 로고    scopus 로고
    • Agency for Health Care Policy and Research, Available at:, Accessed December 10, 2009
    • Agency for Health Care Policy and Research AaAM, 2006. Continuous quality improvement tool released by AHCPR 1998, Available at:, Accessed December 10, 2009. http://www.ahrq.gov/news/press/qitoolpr.htm.
    • (1998) AaAM, 2006. Continuous quality improvement tool released by AHCPR
  • 27
    • 0347586867 scopus 로고    scopus 로고
    • Statistical process control as a tool for research and healthcare improvement
    • Benneyan J.C., Lloyd R.C., Plsek P.E. Statistical process control as a tool for research and healthcare improvement. Qual Saf Health Care 2003, 12(6):458-464.
    • (2003) Qual Saf Health Care , vol.12 , Issue.6 , pp. 458-464
    • Benneyan, J.C.1    Lloyd, R.C.2    Plsek, P.E.3
  • 28
    • 0004223940 scopus 로고
    • Cambridge University Press, Cambridge (UK)
    • Reason J.T. Human error 1990, Cambridge University Press, Cambridge (UK).
    • (1990) Human error
    • Reason, J.T.1
  • 29
    • 0036580468 scopus 로고    scopus 로고
    • Using health care failure mode and effect analysis: the VA National Center for patient safety's prospective risk analysis system
    • 209
    • DeRosier J., Stalhandske E., Bagian J.P., et al. Using health care failure mode and effect analysis: the VA National Center for patient safety's prospective risk analysis system. Jt Comm J Qual Improv 2002, 28(5):248-267. 209.
    • (2002) Jt Comm J Qual Improv , vol.28 , Issue.5 , pp. 248-267
    • DeRosier, J.1    Stalhandske, E.2    Bagian, J.P.3
  • 34
    • 0141953257 scopus 로고    scopus 로고
    • From best evidence to best practice: effective implementation of change in patients' care
    • Grol R., Grimshaw J. From best evidence to best practice: effective implementation of change in patients' care. Lancet 2003, 362(9391):1225-1230.
    • (2003) Lancet , vol.362 , Issue.9391 , pp. 1225-1230
    • Grol, R.1    Grimshaw, J.2
  • 35
    • 0037167027 scopus 로고    scopus 로고
    • What practices will most improve safety? Evidence-based medicine meets patient safety
    • Leape L.L., Berwick D.M., Bates D.W. What practices will most improve safety? Evidence-based medicine meets patient safety. JAMA 2002, 288(4):501-507.
    • (2002) JAMA , vol.288 , Issue.4 , pp. 501-507
    • Leape, L.L.1    Berwick, D.M.2    Bates, D.W.3
  • 36
    • 77950980171 scopus 로고    scopus 로고
    • Random patient safety audits: introduction of a novel safety tool to a large NICU collaborative, Poster Presentation, Pediatric Academic Society Annual Meeting, Washington, DC, May 16,
    • Ursprung R, Edwards WH, Horbar JD, et al. Random patient safety audits: introduction of a novel safety tool to a large NICU collaborative, Poster Presentation, Pediatric Academic Society Annual Meeting, Washington, DC, May 16, 2005.
    • (2005)
    • Ursprung, R.1    Edwards, W.H.2    Horbar J.D3
  • 39
    • 77950982101 scopus 로고    scopus 로고
    • Sentinel events policy and procedures. 2007. Available at: Accessed April,
    • Sentinel events policy and procedures. 2007. Available at: Accessed April, 2009. http://www.Jointcommission.org/SentinelEvents/PolicyandProcedures/.
    • (2009)
  • 40
    • 77951013465 scopus 로고    scopus 로고
    • Sentinel event forms and tools. 2009. Updated April 1, 2009. Accessed December 14,
    • Commission TJ. Sentinel event forms and tools. 2009. Updated April 1, 2009. Accessed December 14, 2009. http://www.jointcommission.org/SentinelEvents/Forms/.
    • (2009)
    • Commission, T.J.1
  • 41
    • 39049137453 scopus 로고    scopus 로고
    • Effectiveness and efficiency of root cause analysis in medicine
    • Wu A.W., Lipshutz A.K., Pronovost P.J. Effectiveness and efficiency of root cause analysis in medicine. JAMA 2008, 299(6):685-687.
    • (2008) JAMA , vol.299 , Issue.6 , pp. 685-687
    • Wu, A.W.1    Lipshutz, A.K.2    Pronovost, P.J.3
  • 42
    • 0034153822 scopus 로고    scopus 로고
    • Root cause analysis in response to a " near miss"
    • Berry K., Krizek B. Root cause analysis in response to a " near miss" J Healthc Qual 2000, 22(2):16-18.
    • (2000) J Healthc Qual , vol.22 , Issue.2 , pp. 16-18
    • Berry, K.1    Krizek, B.2
  • 44
    • 8144223129 scopus 로고    scopus 로고
    • Medication errors in the neonatal intensive care unit: special patients, unique issues
    • Gray J.E., Goldmann D.A. Medication errors in the neonatal intensive care unit: special patients, unique issues. Arch Dis Child Fetal Neonatal Ed 2004, 89(6):F472-F473.
    • (2004) Arch Dis Child Fetal Neonatal Ed , vol.89 , Issue.6
    • Gray, J.E.1    Goldmann, D.A.2
  • 45
    • 0034630115 scopus 로고    scopus 로고
    • Handwashing Compliance by Health Care Workers: The Impact of Introducing an Accessible, Alcohol-Based hand Antiseptic
    • Bischoff W.E., Reynolds T.M., Sessler C.N., et al. Handwashing Compliance by Health Care Workers: The Impact of Introducing an Accessible, Alcohol-Based hand Antiseptic. Arch Intern Med 2000, 160:1017.
    • (2000) Arch Intern Med , vol.160 , pp. 1017
    • Bischoff, W.E.1    Reynolds, T.M.2    Sessler, C.N.3
  • 46
    • 77950968924 scopus 로고    scopus 로고
    • Available at:, Accessed March 9, 2010
    • Available at:, Accessed March 9, 2010. http://www.cdc.gov/handhygiene/.
  • 47
    • 0030391733 scopus 로고    scopus 로고
    • Volume of blood required to detect common neonatal pathogens
    • Schelonka R.L., Chai M.K., Yoder B.A., et al. Volume of blood required to detect common neonatal pathogens. J Pediatr 1996, 129(2):275-278.
    • (1996) J Pediatr , vol.129 , Issue.2 , pp. 275-278
    • Schelonka, R.L.1    Chai, M.K.2    Yoder, B.A.3
  • 48
    • 0037394121 scopus 로고    scopus 로고
    • Implementation of evidence-based potentially better practices to decrease nosocomial infections
    • Kilbride H.W., Wirtschafter D.D., Powers R.J., et al. Implementation of evidence-based potentially better practices to decrease nosocomial infections. Pediatrics 2003, 111(4):e519-e533.
    • (2003) Pediatrics , vol.111 , Issue.4
    • Kilbride, H.W.1    Wirtschafter, D.D.2    Powers, R.J.3
  • 49
    • 0036832506 scopus 로고    scopus 로고
    • Guidelines for the prevention of Intravascular Catheter-Related Infections
    • O'Grady N.P., Alexander M., Dellinger E.P., et al. Guidelines for the prevention of Intravascular Catheter-Related Infections. Pediatrics 2002, 110:e51.
    • (2002) Pediatrics , vol.110
    • O'Grady, N.P.1    Alexander, M.2    Dellinger, E.P.3
  • 50
    • 0028412059 scopus 로고
    • Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion
    • Raad I.I., Hohn D.C., Gilbreath B.J., et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol 1994, 15:231-238.
    • (1994) Infect Control Hosp Epidemiol , vol.15 , pp. 231-238
    • Raad, I.I.1    Hohn, D.C.2    Gilbreath, B.J.3
  • 51
    • 77950986080 scopus 로고    scopus 로고
    • Available at:, Accessed March 9, 2010
    • Available at:, Accessed March 9, 2010. http://www.cdc.gov/mmwr/pdf/rr/rr5111.pdf.
  • 52
    • 0030097291 scopus 로고    scopus 로고
    • Understaffing: a risk factor for infection in the era of downsizing?
    • Farr B.M. Understaffing: a risk factor for infection in the era of downsizing?. Infect Control Hosp Epidemiol 1996, 17(3):147-149.
    • (1996) Infect Control Hosp Epidemiol , vol.17 , Issue.3 , pp. 147-149
    • Farr, B.M.1
  • 54
    • 77950990400 scopus 로고    scopus 로고
    • The Joint Commission, 2010 National Patient Safety Goals. Available at: Accessed March 9,
    • The Joint Commission, 2010 National Patient Safety Goals. Available at: Accessed March 9, 2010. http://www.JointCommission.org/PatientSafety/NationalPatientSafetyGoals/ .
    • (2010)


* 이 정보는 Elsevier사의 SCOPUS DB에서 KISTI가 분석하여 추출한 것입니다.