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| Research article summary (published 29 Sep 2002): |
The Veterans Affairs root cause analysis system in action.
Full Abstract
BACKGROUND:
The patient safety program in the Department of Veterans Affairs (VA) began in 1998, when the National Center for Patient Safety (NCPS) was established to lead the effort on a day-to-day basis. NCPS provides the structure, training, and tools, and VA facilities provide front-line expertise, feedback about the process, and root cause analysis (RCA) of adverse events and close calls.
MONITORING THE PROCESS:
Facility patient safety managers determine the disposition of adverse events and close calls occurring at their facilities. They use a safety assessment code (SAC) to prioritize the actual and potential severity and frequency of an event. BEFORE-AND-AFTER
STUDY:
Before the new RCA system was implemented in 2000, the VA used another adverse event reporting system, focused review (FR). A comparison of the two processes indicates that the RCA process has shifted analyses of adverse events toward a human factors engineering approach-entailing a search for system vulnerabilities rather than human errors and other less actionable root causes.
CASE EXAMPLES:
Two case examples--on hazards in the magnetic resonance imaging (MRI) room and on a cardiac pacemaker malfunction--illustrate how the RCA system works in actual operation. The cases illustrate that broadly applicable, high-impact actions can result from a thorough RCA process.
DISCUSSION:
NCPS monitors the quality and completeness of RCAs through the immediate review and feedback process. Still to be investigated is the effectiveness of RCA actions addressing the hypothesized root causes and contributing factors of the close calls and adverse events.
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Author information
Author/s: Bagian, James P (JP); Gosbee, John (J); Lee, Caryl Z (CZ); Williams, Linda (L); McKnight, Scott D (SD); Mannos, Dea M (DM);
Affiliation: VA National Center for Patient Safety, 2215 Fuller Drive, Ann Arbor, MI 48105, USA.
Journal and publication information
Publication Type: Journal Article
Journal: The Joint Commission journal on quality improvement (Jt Comm J Qual Improv), published in United States. (Language: eng)
Reference: 2002-Oct; vol 28 (issue 10) : pp 531-45
Dates: Created 2002/10/08; Completed 2002/10/24; Revised 2006/08/28;
PMID: 12369156, status: MEDLINE (last retrieval date: 11/6/2008)
Sourced from the National Library of Medicine. Abstract text and other information may be subject to copyright.
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