Improving RCA performance: The Cornerstone Award and the power of positive reinforcement

BMJ Quality and Safety

Volumn 20, Issue 11, 2011, Pages 974-982

  Bagian, James P ^a   King, Beth J ^b   Mills, Peter D ^c,d   McKnight, Scott D ^b  

^a UNIVERSITY OF MICHIGAN MEDICAL SCHOOL   (United States)

^b VA National Center for Patient Safety   (United States)

^c VA National Center for Patient Safety Field Office   (United States)

^d DARTMOUTH MEDICAL SCHOOL   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ADVERSE OUTCOME; ARTICLE; AWARDS AND PRIZES; HEALTH CARE MANAGEMENT; HEALTH CARE SYSTEM; HUMAN; PATIENT SAFETY; REINFORCEMENT; ROOT CAUSE ANALYSIS;

AWARDS AND PRIZES; MEDICAL ERRORS; ROOT CAUSE ANALYSIS; SAFETY MANAGEMENT; UNITED STATES; UNITED STATES DEPARTMENT OF VETERANS AFFAIRS;

EID: 80054903397     PISSN: 20445415     EISSN: None     Source Type: Journal    
DOI: 10.1136/bmjqs.2010.049585     Document Type: Article

References (19)

1. Department of Veterans Affairs, Fact Sheet - January 2009. Office of Public Affairs, Media Relations, Department of Veterans Affairs, Washington DC. http://www.va.gov/opa/publications/factsheets/ fs-department-of-veterans- affairs.pdf (accessed 11 Jul 2011).
2. Bagian JP, Lee C, Gosbee J, 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 2001;27:522-32.
3. Wald H, Shojania KG. Root cause analysis. Making Health Care Safe: A Critical Analysis of Patient Safety Practices. Rockville, MD: Agency for Healthcare Research and Quality, 2001:51-6.
4. Weeks WB, Bagian JP. Developing a culture of safety in the Veterans Health Administration. Eff Clin Pract 2000;3:270-6.
5. Joint Commission on Accreditation of Healthcare Organizations. Section IV: Reviewable Sentinel Events. 2004 Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, IL: The Official Handbook, 2004.
6. Root Cause Analysis in Sweden. http://www.lio.se/Verksamheter/Halso-och- vardutvecklingscentrum/Patientsakerhet/For-patienter/ Patient-safety-in- Ostergotland-Sweden/Root-cause-analysis (accessed 11 Feb 2011).
7. Bagian J, Lee C, Cole J. A method for prioritizing safety related actions. Proceedings of Enhancing Patient Safety and Reducing Errors in Health Care. Chicago IL: National Patient Safety Foundation, 1999:176-85.
8. Bagian JP, Gosbee J, Lee CZ, et al. The Veterans Affairs root cause analysis system in action. Jt Comm J Qual Improv 2002;28:531-45.
9. Reason JT. Human Error. New York: Cambridge University Press, 1990.
10. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ 1998;316:1154-7. (Pubitemid 28156466)
11. Salvendy G, eds. Handbook of Human Factors and Erognomics. Chichester: John Wiley & Sons, Inc, 2006.
12. Mills PD, Neily J, Kinney LM, et al. Effective interventions and implementation strategies to reduce adverse drug events in the Veterans Affairs (VA) system. Qual Saf Health Care 2008;17:37-46. (Pubitemid 351262951)
13. Mills PD, Neily J, Luan D, et al. Using aggregate root cause analysis to reduce falls and related injuries. Jt Comm J Qual Saf 2005;31:21-31.
14. Mills PD, Neily J, Kinney LM, et al. Effective interventions and implementation strategies to reduce adverse drug events in the Veterans Affairs (VA) system. Qual Saf Health Care 2008;17:37-46.
15. VA National Center for Patient Safety Root Cause Analysis Tools. http://www.patientsafety.gov/CogAids/RCA/index.html#page=page-1 (accessed 29 Oct 2010).
16. Department of Veterans Affairs. Handbook 1050.01: VHA National Patient Safety Improvement Handbook. Washington, DC: Veterans Health Administration, 2008.
17. McDowall D, McCleary R, Meidinger EE, et al. Interrupted Time Series Analysis. Beverly Hills, CA: Sage Publications, 1980.
18. Kotter JP. Leading Change. Cambridge: Harvard Business School Press, 1996:117-30.
19. Peters TJ, Waterman RH. In Search of Excellence. Warner Books, 1982.