Background: Root cause analysis (RCA) is a tool for identifying prevention strategies that use a multidisciplinary team approach to analyze healthcare-related adverse events and near misses. A key to improving patient safety and providing quality care is a thorough RCA process that identifies, reports, reviews, and addresses problems related to adverse events and near misses. Problem: The stakeholders want to improve turnaround time for RCA completion without compromising the quality of the process to improve patient safety and quality outcomes. Improving the RCA process is a local practice problem in the suburban academic medical setting based on data from senior directors of patient safety, risk management, and quality. Methods: A revised RCA workflow process was designed for this quality improvement project using the Plan-Do-Study-Act (PDSA) cycle. The project consisted of implementing an enhanced RCA process to improve the timeliness from RCA declaration to analysis completion to ensure that factors leading to significant events are addressed quickly. The mean time for pre- and post-implementation phases were calculated to evaluate the effect of an enhanced process to improve the timeliness of RCA completion. Results: Comparing pre-intervention and post-intervention mean time for RCA declaration to completion was 79.2 to 31.7 days. A t-test to compare the means of RCA days to completion using a level of significance of 0.05 identified a statistical difference between pre-and post-intervention groups. Conclusions: The new RCA process demonstrated a correlation between the intervention and timeliness of RCA completion.

The book follows a proven training outline, including real-life examples and exercises, to teach healthcare professionals and students how to lead effective and successful Root Cause Analysis (RCA) to eliminate patient harm. This book discusses the need for RCA in the healthcare sector, providing practical advice for its facilitation. It addresses when to use RCA, how to create effective RCA action plans, and how to prevent common RCA failures. An RCA training curriculum is also included. This book is intended for those leading RCAs of patient harm events, leaders, students, and patient safety advocates who are interested in gaining more knowledge about RCA in healthcare.

Not only are dialysis access creation and maintenance prone to complications, but patients suffering from end-stage renal disease and its comorbidities generally have a high risk of adverse events during their continuous treatment. Preventive strategies are key to avoid harm and to improve the outcome of the treatment of the growing number of patients with chronic kidney failure, especially as doctors and nurses are not always aware of the consequences of unsafe behavior. This publication is intended for health care professionals – nurses as well as doctors – and aims to raise the awareness of patient safety aspects, combining medical education with evidence-based medicine. After a general overview of the topic, an international panel of authors provides a diversified insight into important concepts and technical tricks essential to create and maintain a functional dialysis access.

Despite the evolution and growing awareness of patient safety, many medical professionals are not a part of this important conversation. Clinicians often believe they are too busy taking care of patients to adopt and implement patient safety initiatives and that acknowledging medical errors is an affront to their skills. Patient Safety provides clinicians with a better understanding of the prevalence, causes and solutions for medical errors; bringing best practice principles to the bedside. Written by experts from a variety of backgrounds, each chapter features an analysis of clinical cases based on the Root Cause Analysis (RCA) methodology, along with case-based discussions on various patient safety topics. The systems and processes outlined in the book are general and broadly applicable to institutions of all sizes and structures. The core ethic of medical professionals is to “do no harm”. Patient Safety is a comprehensive resource for physicians, nurses and students, as well as healthcare leaders and administrators for identifying, solving and preventing medical error.

Are you ready and willing to get to the root causes of problems? As Medicare, Medicaid, and major insurance companies increasingly deny payment for never events, it has become imperative that hospitals and doctors develop new ways to prevent these avoidable catastrophes from recurring. Proactive tools such as root cause analysis (RCA), basic failur

This unique and engaging open access title provides a compelling and ground-breaking account of the patient safety movement in the United States, told from the perspective of one of its most prominent leaders, and arguably the movement’s founder, Lucian L. Leape, MD. Covering the growth of the field from the late 1980s to 2015, Dr. Leape details the developments, actors, organizations, research, and policy-making activities that marked the evolution and major advances of patient safety in this time span. In addition, and perhaps most importantly, this book not only comprehensively details how and why human and systems errors too often occur in the process of providing health care, it also promotes an in-depth understanding of the principles and practices of patient safety, including how they were influenced by today’s modern safety sciences and systems theory and design. Indeed, the book emphasizes how the growing awareness of systems-design thinking and the self-education and commitment to improving patient safety, by not only Dr. Leape but a wide range of other clinicians and health executives from both the private and public sectors, all converged to drive forward the patient safety movement in the US. Making Healthcare Safe is divided into four parts: I. In the Beginning describes the research and theory that defined patient safety and the early initiatives to enhance it. II. Institutional Responses tells the stories of the efforts of the major organizations that began to apply the new concepts and make patient safety a reality. Most of these stories have not been previously told, so this account becomes their histories as well. III. Getting to Work provides in-depth analyses of four key issues that cut across disciplinary lines impacting patient safety which required special attention. IV. Creating a Culture of Safety looks to the future, marshalling the best thinking about what it will take to achieve the safe care we all deserve. Captivatingly written with an “insider’s” tone and a major contribution to the clinical literature, this title will be of immense value to health care professionals, to students in a range of academic disciplines, to medical trainees, to health administrators, to policymakers and even to lay readers with an interest in patient safety and in the critical quest to create safe care.