Cause-and-effect Mapping of Critical Events

Critical Care Nursing Clinics of North America

Volumn 22, Issue 2, 2010, Pages 243-251

  Graves, Krisanne ^a   Simmons, Debora ^a,b,c,d   Galley, Mark D ^e  

^a TEXAS WOMAN'S UNIVERSITY   (United States)

^b TEXAS A AND M UNIVERSITY   (United States)

^c NORTHWESTERN UNIVERSITY   (United States)

^d ThinkReliabiliy ^*  (United States)

^e ThinkReliabiliy   (United States)

Author keywords

Cause and effect diagram; Event analysis; Process improvement; System

Indexed keywords

ANTICOAGULANT AGENT; HEPARIN;

ACCREDITATION; DRUG LABELING; EPIDEMIOLOGY; HUMAN; MEDICATION ERROR; METHODOLOGY; MORTALITY; ORGANIZATION; PROBLEM SOLVING; REVIEW; SAFETY; STATISTICAL ANALYSIS; STATISTICS; SYSTEM ANALYSIS; THINKING; TOTAL QUALITY MANAGEMENT; TREATMENT OUTCOME; UNITED STATES;

ANTICOAGULANTS; CAUSALITY; DATA INTERPRETATION, STATISTICAL; DRUG LABELING; HEPARIN; HUMANS; INDIANA; INSTITUTE OF MEDICINE (U.S.); JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS; LOS ANGELES; MEDICATION ERRORS; OUTCOME AND PROCESS ASSESSMENT (HEALTH CARE); PROBLEM SOLVING; SAFETY MANAGEMENT; SYSTEMS ANALYSIS; THINKING; TOTAL QUALITY MANAGEMENT; UNITED STATES;

EID: 77954843027     PISSN: 08995885     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.ccell.2010.03.012     Document Type: Review

References (23)

1. To err is human: building a safer health system 2000, National Academies Press, Washington, DC. L.T. Kohn, J.M. Corrigan, M.S. Donaldson (Eds.).
2. Landro L. Catching deadly drug mistakes. Wall St J 2010, Available at:, Accessed April 15, 2010. http://online.wsj.com/article/SB10001424052748703626604575010932945077528.html?KEYWORDS=Catching+Deadly+Drug+Mistakes.
3. Wachter R.M., Shojania K. Internal bleeding: the truth behind America's terrifying epidemic of medical mistakes 2005, Rugged Land, New York.
4. Senge P.M. The fifth discipline: the art & practice of the learning organization 1994, Currency Doubleday, New York.
5. Tague N.R. The quality toolbox 2005, ASQ Quality Press, Milwaukee (WI).
6. Donabedian A. The quality of care: how can it be assessed?. JAMA 1988, 260(12):1743-1748.
7. Plsek P. Appendix B: redesigning health care with insights from the science of complex adaptive systems. Crossing the quality chasm: a new health system for the 21st century 2001, 309-322. National Academies Press, Washington, DC. J.M. Corrigan, M.S. Donaldson, L.T. Kohn (Eds.).
8. Poniatowski L., Stanley S., Youngberg B. Using information to empower nurse managers to become champions for patient safety. Nurs Adm Q 2005, 29:72-77.
9. Available at:, Accessed March 5, 2010. http://www.thefreedictionary.com/process.
10. Reason J. Human error 1990, Cambridge University Press, New York.
11. Patient safety: achieving a new standard for care 2004, National Academies Press, Washington, DC. P. Aspden, J.M. Corrigan, J. Wolcott (Eds.).
12. Wakefield D.S., Wakefield B.J., Uden-Holman T., et al. Perceived barriers in reporting medication administration errors. Best Pract Benchmarking Healthc 1996, 1(4):191-197.
13. Martin S.K., Etchegaray J.M., Simmons D., et al. Development and implementation of the University of Texas close call reporting system 2005, Agency for Healthcare Research and Quality, Rockville (MD), Publication nos. 050021(2).
14. Ahoy C. Process mapping Available at:, Accessed March 5, 2010. http://www.fpm.iastate.edu/worldclass/process_mapping.asp.
15. The Joint Commission Sentinel events Available at:, Accessed March 5, 2010. http://www.jointcommission.org/NR/rdonlyres/F84F9DC6-A5DA-490F-A91F-A9FCE26347C4/0/SE_chapter_july07.pdf.
16. The Joint Commission A framework for a root cause analysis and action plan in response to a sentinel event Available at:, Accessed March 5, 2010. http://www.jointcommission.org/SentinelEvents/Forms/.
17. Veteran's Administration National Center for Patient Safety. NCPS triage cards for root cause analysis. October 2001.
18. Jackson P.Z., McKergow M. Solutions focus 2002, Nicolas Brealey Publishing, London.
19. Perrow C. Normal accidents: living with high-risk technologies 1999, Princeton University Press, Princeton (NJ).
20. Available at:, Accessed April 15, 2010. http://www.nursingadvocacy.org/news/2006/sep/24_indianapolis.html.
21. Available at:, Accessed February 15, 2008. http://abcnews.go.com/WNT/Health/story%3Fid=2465287&page=1.
22. Battles J.B., Kaplan H.S., Van der Schaaf T.W., et al. The attributes of medical event-reporting systems: experience with a prototype medical event-reporting system for transfusion medicine. Arch Pathol Lab Med 1998, 122(3):231-238.
23. Available at:, Accessed April 15, 2010. http://blogs.wsj.com/health/2008/03/14/baxters-other-heparin-problem-dennis-quaid/tab/article/.