Root cause analysis of ambulatory adverse drug events that present to the emergency department

Journal of Patient Safety

Volumn 12, Issue 3, 2016, Pages 119-124

  Gertler, Sarah A ^a   Coralic, Zlatan ^a   Lopez, Andrea ^a,b   Stein, John C ^a   Sarkar, Urmimala ^a,b  

^a SAN FRANCISCO GENERAL HOSPITAL   (United States)

^b UNIVERSITY OF CALIFORNIA   (United States)

Author keywords

Adverse drug events; Patient safety; Qualitative analysis; Root cause analysis

Indexed keywords

ADULT; AGED; AMBULATORY CARE; DRUG-RELATED SIDE EFFECTS AND ADVERSE REACTIONS; FEMALE; HOSPITAL EMERGENCY SERVICE; HUMAN; MALE; MIDDLE AGED; OUTPATIENT; PATIENT SAFETY; PHARMACIST; PHYSICIAN; RISK ASSESSMENT; ROOT CAUSE ANALYSIS;

ADULT; AGED; AMBULATORY CARE; DRUG-RELATED SIDE EFFECTS AND ADVERSE REACTIONS; EMERGENCY SERVICE, HOSPITAL; FEMALE; HUMANS; MALE; MIDDLE AGED; OUTPATIENTS; PATIENT SAFETY; PHARMACISTS; PHYSICIANS; RISK ASSESSMENT; ROOT CAUSE ANALYSIS;

EID: 84894417244     PISSN: 15498417     EISSN: 15498425     Source Type: Journal    
DOI: 10.1097/PTS.0000000000000072     Document Type: Article

References (27)

1. Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348:1556-1564.
2. Sarkar U, Lopez A, Maselli JH, et al. Adverse drug events in U.S. adult ambulatory medical care. Health Serv Res. 2011;46:1517-1533.
3. Budnitz DS, Pollock DA, Weidenbach KN, et al. National surveillance of emergency department visits for outpatient adverse drug events. JAMA. 2006;296:1858-1866.
4. Budnitz DS, Lovegrove MC, Shehab N, et al. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365:2002-2012.
5. Budnitz DS, Shehab N, Kegler SR, et al. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med. 2007;147:755-765.
6. Haddon W Jr. A logical framework for categorizing highway safety phenomena and activity. J Trauma. 1972;12:193-207.
7. Rooney J, Vanden Heuvel L. Root cause analysis for beginners. Quality Progress. 2004;37:45-56.
8. Longo DR, Hewett JE, Ge B, et al. The long road to patient safety: a status report on patient safety systems. JAMA. 2005;294:2858-2865.
9. Iedema RA, Jorm C, Braithwaite J, et al. A root cause analysis of clinical error: confronting the disjunction between formal rules and situated clinical activity. Soc Sci Med. 2006;63:1201-1212.
10. Iedema RA, Jorm C, Long D, et al. Turning the medical gaze in upon itself: root cause analysis and the investigation of clinical error. Soc Sci Med. 2006;62:1605-1615.
11. Brown J, Doloresco Iii F, Mylotte JM. "Never events": not every hospital-acquired infection is preventable. Clin Infect Dis. 2009;49:743-746.
12. Sarkar U, Handley MA, Gupta R, et al. What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes. Qual Saf Health Care. 2010;19:223-228.
13. Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med. 2006;145:488-496.
14. Friedman AL, Geoghegan SR, Sowers NM, et al. Medication errors in the outpatient setting: classification and root cause analysis. Arch Surg. 2007;142:278-283; discussion 84.
15. Elder NC, Jacobson CJ, Zink T, et al. How experiencing preventable medical problems changed patients' interactions with primary health care. Ann Fam Med. 2005;3:537-544.
16. Gupta P, Varkey P. Developing a tool for assessing competency in root cause analysis. Jt Comm J Qual Patient Saf. 2009;35:36-42.
17. Buetow S, Kiata L, Liew T, et al. Approaches to reducing the most important patient errors in primary health-care: patient and professional perspectives. Health Soc Care Community. 2010;18:296-303.
18. Buetow S, Elwyn G. Patient safety and patient error. Lancet. 2007;369:158-161.
19. Sarkar U, Schillinger D, Bibbins-Domingo K, et al. Patient-physicians' information exchange in outpatient cardiac care: time for a heart to heart? Patient Educ Couns. 2011;85:173-179.
20. Tarn DM, Paterniti DA, Kravitz RL, et al. How much time does it take to prescribe a new medication? Patient Educ Couns. 2008;72:311-319.
21. Tarn DM, Paterniti DA, Kravitz RL, et al. How do physicians conduct medication reviews? J Gen Intern Med. 2009;24:1296-1302.
22. Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166:565-571.
23. Tinetti ME, Bogardus ST Jr, Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med. 2004;351:2870-2874.
24. Fried TR, Tinetti ME, Iannone L. Primary care clinicians' experiences with treatment decision making for older persons with multiple conditions. Arch Intern Med. 2011;171:75-80.
25. Fick DM, Cooper JW, Wade WE, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163:2716-2724.
26. Steinman MA, Handler SM, Gurwitz JH, et al. Beyond the prescription: medication monitoring and adverse drug events in older adults. J Am Geriatr Soc. 2011;59:1513-1520.
27. Buntin MB, Jain SH, Blumenthal D. Health information technology: laying the infrastructure for national health reform. Health Aff (Millwood). 2010;29:1214-1219.