MARC details
| 000 -LEADER |
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| fixed length control field |
02746nam a22003737a 4500 |
| 008 - FIXED-LENGTH DATA ELEMENTS--GENERAL INFORMATION |
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| fixed length control field |
140821s20132013 xxu||||| |||| 00| 0 eng d |
| 022 ## - INTERNATIONAL STANDARD SERIAL NUMBER |
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| International Standard Serial Number |
1074-4797 |
| 040 ## - CATALOGING SOURCE |
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| Original cataloging agency |
Ovid MEDLINE(R) |
| 099 ## - LOCAL FREE-TEXT CALL NUMBER (OCLC) |
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| PMID |
24078204 |
| 245 ## - TITLE STATEMENT |
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| Title |
An evidence-based toolkit for the development of effective and sustainable root cause analysis system safety solutions. |
| 251 ## - Source |
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| Source |
Journal of Healthcare Risk Management. 33(2):11-20, 2013. |
| 252 ## - Abbreviated Source |
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| Abbreviated source |
J Healthc Risk Manag. 33(2):11-20, 2013. |
| 253 ## - Journal Name |
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| Journal name |
Journal of healthcare risk management : the journal of the American Society for Healthcare Risk Management |
| 266 ## - Date added to catalog |
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| Date added to catalog |
2014-08-21 |
| 520 ## - SUMMARY, ETC. |
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| Abstract |
Root cause analysis (RCA) after adverse events in healthcare is a standard practice at many institutions. However, healthcare has failed to see a dramatic improvement in patient safety over the last decade. In order to improve the RCA process, this study used systems safety science, which is based partly on human factors engineering principles and has been applied with success in other high-risk industries like aviation. A multi-institutional dataset of 334 RCA cases and 782 solutions was analyzed using qualitative methods. A team of safety science experts developed a model of 13 RCA solutions categories through an iterative process, using semi-structured interview data from 44 frontline staff members from 7 different hospital-based unit types. These categories were placed in a model and toolkit to help guide RCA teams in developing sustainable and effective solutions to prevent future adverse events. This study was limited by its retrospective review of cases and use of interviews rather than clinical observations. In conclusion, systems safety principles were used to develop guidelines for RCA teams to promote systems-level sustainable and effective solutions for adverse events. 2013 American Society for Healthcare Risk Management of the American Hospital Association. |
| 546 ## - LANGUAGE NOTE |
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| Language note |
English |
| 650 ## - SUBJECT ADDED ENTRY--TOPICAL TERM |
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| Topical term or geographic name entry element |
*Medical Errors/pc [Prevention & Control] |
| 650 ## - SUBJECT ADDED ENTRY--TOPICAL TERM |
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| Topical term or geographic name entry element |
*Patient Safety/st [Standards] |
| 650 ## - SUBJECT ADDED ENTRY--TOPICAL TERM |
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| Topical term or geographic name entry element |
*Root Cause Analysis/mt [Methods] |
| 650 ## - SUBJECT ADDED ENTRY--TOPICAL TERM |
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| Topical term or geographic name entry element |
*Safety Management/mt [Methods] |
| 650 ## - SUBJECT ADDED ENTRY--TOPICAL TERM |
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| Topical term or geographic name entry element |
Databases, Factual |
| 650 ## - SUBJECT ADDED ENTRY--TOPICAL TERM |
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| Topical term or geographic name entry element |
Humans |
| 650 ## - SUBJECT ADDED ENTRY--TOPICAL TERM |
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| Topical term or geographic name entry element |
Interviews as Topic |
| 650 ## - SUBJECT ADDED ENTRY--TOPICAL TERM |
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| Topical term or geographic name entry element |
Qualitative Research |
| 650 ## - SUBJECT ADDED ENTRY--TOPICAL TERM |
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| Topical term or geographic name entry element |
Retrospective Studies |
| 650 ## - SUBJECT ADDED ENTRY--TOPICAL TERM |
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| Topical term or geographic name entry element |
Root Cause Analysis/st [Standards] |
| 650 ## - SUBJECT ADDED ENTRY--TOPICAL TERM |
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| Topical term or geographic name entry element |
Safety Management/og [Organization & Administration] |
| 650 ## - SUBJECT ADDED ENTRY--TOPICAL TERM |
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| Topical term or geographic name entry element |
Safety Management/st [Standards] |
| 651 ## - SUBJECT ADDED ENTRY--GEOGRAPHIC NAME |
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| Institution |
MedStar Institute for Innovation |
| 657 ## - INDEX TERM--FUNCTION |
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| Medline publication type |
Journal Article |
| 700 ## - ADDED ENTRY--PERSONAL NAME |
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| Local Authors |
Fairbanks, Rollin JT |
| 790 ## - Authors |
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| All authors |
Bisantz AM, Fairbanks RJ, Hegde S, Hettinger AZ, Lewis VL, Rackoff AS, Wears RL, Wreathall J |
| 942 ## - ADDED ENTRY ELEMENTS (KOHA) |
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| Koha item type |
Journal Article |
| Item type description |
Journal article |
