Clinical errors: Implementing root cause analysis in an area health service

References

• La Pietra L, Calligaris L, Molendini L, et al. Medical errors and clinical risk management: state of the art. Acta Otorhinolaryngol Ital. 2005;25(6):339–346.
   PubMedGoogle Scholar
• Nasiripour A, Raeissi P, Tabibi S, et al. Hidden threats inducing medical errors in Tehran public hospitals. Bimonthly J Hormozgan Univ Med Sci. 2011;15(2):152–162.
   Google Scholar
• Singer S, Lin S, Falwell A, et al. Relationship of safety climate and safety performance in hospitals. Health Serv Res. 2009 Apr;44(2 Pt 1):399–421. doi:10.1111/j.1475-6773.2008.00918.x. PubMed PMID: 19178583; PubMed Central PMCID: PMCPMC2677046. eng.
   PubMed Web of Science ®Google Scholar
• Organization WH. Summary of the evidence on patient safety: implications for research. (Cited 2017).9] 2008. Available from: http://whqlibdoc.who.int/publications/2008/9789241596541_eng.pdf.
   Google Scholar
• Johna S, Tang T, Saidy M. Patient safety in surgical residency: root cause analysis and the surgical morbidity and mortality conference – case series from clinical practice. Perm J. 2012;16(1):67.
   PubMedGoogle Scholar
• Perotti V, Sheridan MM. Root cause analysis of critical events in neurosurgery, New South Wales. ANZ J Surg. 2015;85(9):626–630.
   PubMed Web of Science ®Google Scholar
• Baylina P, Moreira P. Challenging healthcare-associated infections: a review of healthcare quality management issues. J Manage Marketing Healthcare. 2011;4(4):254–264.
   Google Scholar
• Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ Br Med J (Online). 2016;353.
   Google Scholar
• Siddiqi S, Elasady R, Khorshid I, et al. Patient safety friendly hospital initiative: from evidence to action in seven developing country hospitals. Int J Qual Health Care. 2012;24(2):144–151.
   PubMed Web of Science ®Google Scholar
• Badr HE, AlFadalah T, El-Jardali F. Towards promoting patient safety practices: baseline assessment of patient safety culture in three private hospitals. Int J Healthc Manag. 2017;84: 1–8.
   Google Scholar
• Ravaghi H, Sajadi H. Research priorities for patient safety in Iran. ‌Hakim Health Sys Res. 2014;16(4):358–366.
   Google Scholar
• Teixeira TCA. Cassiani SHDB. Root cause analysis: evaluation of medication errors at a university hospital. Revista da Escola de Enfermagem da USP. 2010;44(1):139–146.
   PubMed Web of Science ®Google Scholar
• Wu AW, Lipshutz AK, Pronovost PJ. Effectiveness and efficiency of root cause analysis in medicine. JAMA. 2008;299(6):685–687.
   PubMed Web of Science ®Google Scholar
• Yee KC, Wong MC, Turner P. Medical error management and the role of information technology--a new approach to investigating medical handover in acute care settings. Stud Health Technol Inform. 2006;124:679–684.
   PubMedGoogle Scholar
• Kim CW, Myung SJ, Eo EK, et al. Improving disclosure of medical error through educational program as a first step toward patient safety. BMC Med Educ. 2017;17(1):307.
   Google Scholar
• Venier A-G. Root cause analysis to support infection control in healthcare premises. J Hosp Infect. 2015;89(4):331–334.
   PubMed Web of Science ®Google Scholar
• Tran DT, Johnson M. Classifying nursing errors in clinical management within an Australian hospital. Int Nurs Rev. 2010;57(4):454–462.
   PubMed Web of Science ®Google Scholar
• Livotov P. TRIZ and innovation management innovative product development and theory of inventive problem solving. INNOVATOR TriS Europe. 2008:1–30. Available from: //triz.it/triz_papers/2008%20TRIZ%20and%20Innovation%20Management.pdf (accessed 11 April2012).
   Google Scholar
• Ebrahimipour H, Vafaee-Najar A, Hosseini SH, et al. Proactive risk assessment of the laboratory management process inGhaem Hospital, Mashhad (2013). J Paramedical Sci. 2015;6(2):339–346.
   Google Scholar
• Nasiripour A, Raeissi P, Tabibi S. Development and compilation of strategies and preventive measures for medical errors in public hospitals in Tehran. J Health Admin. 2011;14(44):21–32.
   Google Scholar
• Steele CF, Rubin G, Fraser S. Error classification in community optometric practice – a pilot project. Ophthalmic Physiolo Opt J Br Coll Ophthalmic Opticians (Optometrists). 2006 Jan;26(1):106–110. doi:10.1111/j.1475-1313.2005.00360.x. PubMed PMID: 16390489; eng.
   PubMed Web of Science ®Google Scholar
• Falchuk KH, Falchuk E. The misdiagnosis epidemic: five root causes and the growing demand for more patient-centric care. Int J Healthc Manag. 2012;5(1):61–65.
   Google Scholar
• DoP H. California Department of Public Health: Health and Human Services Agency Sacramento: California 2007. Available from: http://www.cdph.ca.gov/certlic/facilities/documents/LNCAFL.
   Google Scholar
• Atif R, Butt B. Medical error in Canada: issues related to reporting of medical error and methods to increase reporting. MUMJ. 2010;7(1):15–18.
   Google Scholar
• Bonfant G, Belfanti P, Paternoster G, et al. Clinical risk analysis with failure mode and effect analysis (FMEA) model in a dialysis unit. J Nephrol. 2010 Jan–Feb;23(1):111–118. PubMed PMID: 20091494; eng.
   PubMed Web of Science ®Google Scholar
• Lockley SW, Barger LK, Ayas NT, et al. Effects of health care provider work hours and sleep deprivation on safety and performance. Joint Commission J Qual Patient Saf. 2007;33(11):7–18.
   PubMedGoogle Scholar
• Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Internal Med. 2005 Jul 11;165(13):1493–1499. doi:10.1001/archinte.165.13.1493. PubMed PMID: 16009864; eng.
   PubMed Web of Science ®Google Scholar
• Morbi AH, Hamady MS, Riga CV, et al. Reducing error and improving efficiency during vascular interventional radiology: implementation of a preprocedural team rehearsal. Radiology. 2012 Aug;264(2):473–483. doi:10.1148/radiol.12110530. PubMed PMID: 22668564; eng.
   PubMed Web of Science ®Google Scholar
• Barzdins J. Developing health care management skills in times of crisis: a review from Baltic region. Int J Healthc Manage. 2012;5(3):129–140.
   Google Scholar
• Taleghani YM, Rezaei F, Sheikhbardsiri H. Risk assessment of the emergency processes: healthcare failure mode and effect analysis. World J Emergency Med. 2016;7(2):97.
   PubMed Web of Science ®Google Scholar
• Battles JB, Shea CE. A system of analyzing medical errors to improve GME curricula and programs. Acad Med J Assoc Am Med Coll. 2001 Feb;76(2):125–133. PubMed PMID: 11158830; eng.
   Google Scholar
• Dehnavieh R, Ebrahimipour H, Molavi-Taleghani Y, et al. Proactive risk assessment of blood transfusion process, in pediatric emergency, using the health care failure mode and effects analysis (HFMEA). Glob J Health Sci. 2015;7(1):322.
   Google Scholar
• M H MTN, Shahbazi S, et al. Correlation of human resource strategies based on Allen Ylsy Model with organizational performance staff in Aiat Allah Kashani Hospital. J Health Promotion Manage. 2013;3(2):36–44.
   Google Scholar
• Wong J, Beglaryan H. Strategies for hospitals to improve patient safety: A review of the research;2004. Available from: www.providence.on.ca/.../Change-Foundation-Improve-Patient-Safety.
   Google Scholar
• Scandelius R, Pink S. Contract management and monitoring in healthcare. J Manage Marketing Healthc. 2008;1(4):351–361.
   Google Scholar
• (WHO/EMRO). Report on the inter country consultation for developing a regional strategy for patient safety. Kuwait City: World Health Organization Regional Office for the Eastern Mediterranean; 2004.
   Google Scholar
• Pexton C. Strategies for improving patient safety in the hospital;2004 . Available from: www.isixsigma
   Google Scholar
• Karami M. Development of key performance indicators for academic radiology departments. Int J Healthc Manage. 2017;10(4):275–280.
   Web of Science ®Google Scholar
• Brook OR, Kruskal JB, Eisenberg RL, et al. Root cause analysis: learning from adverse safety events. Radiographics. 2015;35(6):1655–1667.
   PubMed Web of Science ®Google Scholar
• care OoSaAoh. National accreditation standards for Iranian hospitals ministry of health education medical. tehran; 2015 [cited 1395 desamber]. Available from: http://madanihosp.tbzmed.ac.ir/uploads/User/702/.
   Google Scholar
• Iedema RAM, 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(7):1605–1615.
   PubMed Web of Science ®Google Scholar
• Braithwaite J, Westbrook MT, Mallock NA, et al. Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme. Qual Saf Health Care. 2006;15(6):393–399.
   PubMedGoogle Scholar