A cross-sectional study on the relationship between utilization of root cause analysis and patient safety at 139 department of veterans affairs medical centers

Joint Commission Journal on Quality and Patient Safety

Volumn 39, Issue 1, 2013, Pages 32-37

  Percarpio, Katherine B ^a,b   Watts, B Vince ^a,c  

^a DEPARTMENT OF VETERANS AFFAIRS   (United States)

^b LUCILE PACKARD CHILDREN S HOSPITAL   (United States)

^c DARTMOUTH MEDICAL SCHOOL   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; CROSS-SECTIONAL STUDY; HEALTH CARE QUALITY; HOSPITAL COST; HUMAN; LENGTH OF STAY; MULTICENTER STUDY; ORGANIZATION AND MANAGEMENT; PATIENT SAFETY; PUBLIC HOSPITAL; ROOT CAUSE ANALYSIS; STATISTICS; UNITED STATES;

CROSS-SECTIONAL STUDIES; HOSPITAL COSTS; HOSPITALS, VETERANS; HUMANS; LENGTH OF STAY; PATIENT SAFETY; QUALITY INDICATORS, HEALTH CARE; ROOT CAUSE ANALYSIS; UNITED STATES;

MLCS; MLOWN;

EID: 84874445679     PISSN: 15537250     EISSN: None     Source Type: Journal    
DOI: 10.1016/S1553-7250(13)39006-0     Document Type: Article

References (36)

1. Institute of Medicine. To Err is Human: Building a Safer Healthcare System. Washington, DC: National Academy Press; 1999.
2. Classen DC, et al. 'Global Trigger Tool' shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood). 2011; 30(4): 581-589.
3. Levinson DR. Adverse Events in Hospitals: Medicare's Responses to Alleged Serious Events. Report No. OEI-01-08-00590. Washington, DC: US Department of Health & Human Services, Office of Inspector General, Oct 2011. Accessed Dec 3, 2012. https://oig.hhs.gov/oei/reports/oei-01-08-00590.pdf.
4. The Joint Commission. Sentinel Event Policy and Procedures. Jan 1, 2012. Accessed Dec 3, 2012. http://www.jointcommission.org/Sentinel-Event-Policy-and- Procedures/.
5. O'Leary DS. President's Column: The Sentinel Event Policy: A work in progress. Jt Comm Perspect. 1996; 16(6): 2-3.
6. Bagian J P, et al. The Veterans Affairs root cause analysis system in action. Jt Comm J Qual Improv. 2002; 28(10): 531-545.
7. Kaplan HS, Fastman BR. Organization of event reporting data for sense making and system improvement. Qual Saf Health Care. 2003; 12 Suppl 2: ii68-72. (Pubitemid 37542043)
8. Motschman TL, Moore SB. Corrective and preventive action. Transfus Sci. 1999; 21(2): 163-178.
9. Wald H, Shojania KG. Root Cause Analysis. In Making Healthcare Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43. Rockville, MD2001, 51-56. Accessed Dec 3, 2012. http://www.ahrq.gov/clinic/ptsafety/pdf/ptsafety.pdf.
10. Woloshynowych M, et al. The investigation and analysis of critical incidents and adverse events in healthcare. Health Technol Assess. 2005; 9(19): 1-143.
11. Wu AW, Lipshutz AK, Pronovost PJ. Effectiveness and efficiency of root cause analysis in medicine. JAMA. 2008 Feb 13; 299(6): 685-687. (Pubitemid 351252728)
12. Percarpio KB, Watts BV, Weeks WB. The effectiveness of root cause analysis: What does the literature tell us? Jt Comm J Qual Patient Saf. 2008; 34(7): 391-398.
13. Nicolini D, Waring J, Mengis J. Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the gap. Soc Sci Med. 2011; 73(2): 217-225.
14. U.S. Department of Veterans Affairs. Ensuring Correct Surgery and Invasive Procedures. May 17, 2010. Accessed Dec 3, 2012. http://www1.va.gov/ vhapublications/ViewPublication.asp?pub-ID=2243.
15. The Joint Commission. Universal Protocol. Accessed Dec 3, 2012. http://www.jointcommission.org/standards-information/up.aspx.
16. Personal communication between the author [B.V.W.] and James Bagian, MD, Chair, Patient Safety Advisor Group, The Joint Commission, Oakbrook Terrace, IL, Jul 26, 2011.
17. US Food and Drug Administration. Benzocaine Sprays. Feb 13, 2006. Accessed Dec 3, 2012. http://www.fda.gov/Safety/MedWatch/SafetyInformation/ SafetyAlertsforHumanMedicalProducts/ucm150501.htm.
18. Mills PD, et al. Actions and implementation strategies to reduce suicidal events in the Veterans Health Administration. Jt Comm J Qual Patient Saf. 2006; 32(3): 130-141.
19. Mills PD, et al. A checklist to identify inpatient suicide hazards in Veterans Affairs hospitals. Jt Comm J Qual Patient Saf. 2010; 36(2): 87-93.
20. US Department of Veterans Affairs, National Center for Patient Safety. NCPS Root Cause Analysis Tools. Accessed Nov 27, 2012. http://www.patientsafety. gov/CogAids/RCA/index.html#page=page-1.
21. US Department of Veterans Affairs, VA Information Resource Center. VHA Medical SAS Datasets: Overview. (Updated Oct 29, 2012.) Accessed Dec 3, 2012. http://www.virec.research.va.gov/MedSAS/Overview.htm.
22. Agency for Healthcare Research and Quality (AHRQ). Patient Safety Indicators: Technical Specifications, Version 4.0. Rockville, MD: AHRQ, Jun 2009.
23. McDonald KM, et al. Measures of Patient Safety Based on Hospital Administrative Data-The Patient Safety Indicators. Technical Review 5. AHRQ Publication No. 02-0038. Rockville, MD: Agency for Healthcare Research and Quality, Aug 2002. Accessed Dec 3, 2012. http://www.ncbi.nlm.nih.gov/books/ NBK43854/pdf/TOC.pdf.
24. West AN, Weeks WB, Bagian J P. Rare adverse medical events in VA inpatient care: Reliability limits to using patient safety indicators as performance measures. Health Serv Res. 2008; 43(1 Pt 1):249-266. (Pubitemid 351601532)
25. Cevasco M, et al. Validity of the AHRQ Patient Safety Indicator "central venous catheter-related bloodstream infections." J Am Coll Surg. 2011; 212(6): 984-990.
26. Chen Q, et al. Detecting patient safety indicators: How valid is "foreign body left during procedure" in the Veterans Health Administration? J Am Coll Surg. 2011; 212(6): 977-983.
27. Borzecki AM, et al. How valid is the AHRQ Patient Safety Indicator "postoperative physiologic and metabolic derangement"? J Am Coll Surg. 2011; 212(6): 968-976.
28. Kaafarani HM, et al. Validity of selected Patient Safety Indicators: Opportunities and concerns. J Am Coll Surg. 2011; 212(6): 924-934.
29. Rosen AK, Itani KM. Validating the Patient Safety Indicators in the Veterans Health Administration: Are they ready for prime time? J Am Coll Surg. 212(6): 921-923.
30. Horwitz LI, et al. Failure to rescue: Validation of an algorithm using administrative data. Med Care. 2007; 45(4): 283-287.
31. Polancich S, Restrepo E, Prosser J. Cautious use of administrative data for decubitus ulcer outcome reporting. Am J Med Qual. 2006; 21(4): 262-268. (Pubitemid 44035785)
32. Houchens RL, Elixhauser A, Romano PS. How often are potential patient safety events present on admission? Jt Comm J Qual Patient Saf. 2008; 34(3): 154-163.
33. Gaskin DJ, et al. Do minority patients use lower quality hospitals? Inquiry. 2011; 48(3): 209-220.
34. Groene O, et al. Is the maturity of hospitals' quality improvement systems associated with measures of quality and patient safety? BMC Health Serv Res. 2011 Dec 20; 11:344.
35. Rivard PE, Parker VA, Rosen AK. Quality improvement for patient safety: Project-level versus program-level learning. Health Care Manage Rev. Epub 2012 Jan 20.
36. Rosen AK, et al. Validating the Patient Safety Indicators in the Veterans Health Administration: Do they accurately identify true safety events? Med Care. 2012; 50(1): 74-85.