| Preventing Wrong Site, Procedure, and Patient Events Using a Common Cause Analysis. | |
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MedLine Citation:
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PMID: 21835810 Owner: NLM Status: Publisher |
Abstract/OtherAbstract:
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The medical center experienced 8 wrong site/procedure/patient events between April 2008 and January 2010. A common cause analysis (CCA) was conducted on all 8 events to determine the causal factors of these events. After a sentinel event is identified, the medical center conducts a root cause analysis (RCA) within 45 days of the event. A CCA helps recognize trends and establish themes identified from each RCA. The CCA revealed that there were 22 occurrences of failure modes noted in the category of Rules, Policies, and Procedures and 17 failure modes present in the category of Human Factors: Scheduling and Fatigue. A multidisciplinary team was assembled to confirm the failure modes identified in the CCA and to develop processes to address these failure modes. No further wrong site, procedure, or person events have occurred over the last year. |
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Authors:
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Renee Mallett; Megan Conroy; Lisa Zaidain Saslaw; Susan Moffatt-Bruce |
Publication Detail:
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Type: JOURNAL ARTICLE Date: 2011-8-10 |
Journal Detail:
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Title: American journal of medical quality : the official journal of the American College of Medical Quality Volume: - ISSN: 1555-824X ISO Abbreviation: - Publication Date: 2011 Aug |
Date Detail:
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Created Date: 2011-8-12 Completed Date: - Revised Date: - |
Medline Journal Info:
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Nlm Unique ID: 9300756 Medline TA: Am J Med Qual Country: - |
Other Details:
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Languages: ENG Pagination: - Citation Subset: - |
Affiliation:
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The Ohio State University, Columbus, Ohio. |
Export Citation:
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From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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