TY - JOUR
T1 - Root cause analyses performed in a children's hospital
T2 - events, action plan strength, and implementation rates.
AU - Morse, Rustin B.
AU - Pollack, Murray M.
PY - 2012/1/1
Y1 - 2012/1/1
N2 - This study describes the types of events leading to the performance of root cause analyses (RCA) and the implementation rate and quality of the action plans developed for RCAs performed at a free standing children's hospital. Twenty serious adverse events resulting in RCAs took place between January 2007 and June 2009. A wide variety of events triggered RCAs however, 30% involved medication errors. Seventy-eight action plans were developed with an average of 3.9 ± 1.3 per RCA. Action plans were classified as weaker 46% of the time, intermediate 44% of the time, and stronger 10% of the time. Intermediate or stronger action plans were developed to address 90% of the events. Ninety-five percent of the action plans were implemented. This study demonstrates that RCA can be effectively utilized to consistently generate moderate and high impact action plans to address a diverse array of adverse events within a children's hospital. Near complete implementation of action plans can be achieved.
AB - This study describes the types of events leading to the performance of root cause analyses (RCA) and the implementation rate and quality of the action plans developed for RCAs performed at a free standing children's hospital. Twenty serious adverse events resulting in RCAs took place between January 2007 and June 2009. A wide variety of events triggered RCAs however, 30% involved medication errors. Seventy-eight action plans were developed with an average of 3.9 ± 1.3 per RCA. Action plans were classified as weaker 46% of the time, intermediate 44% of the time, and stronger 10% of the time. Intermediate or stronger action plans were developed to address 90% of the events. Ninety-five percent of the action plans were implemented. This study demonstrates that RCA can be effectively utilized to consistently generate moderate and high impact action plans to address a diverse array of adverse events within a children's hospital. Near complete implementation of action plans can be achieved.
UR - http://www.scopus.com/inward/record.url?scp=84879492072&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=84879492072&partnerID=8YFLogxK
U2 - 10.1111/j.1945-1474.2011.00140.x
DO - 10.1111/j.1945-1474.2011.00140.x
M3 - Article
C2 - 22059523
AN - SCOPUS:84879492072
VL - 34
SP - 55
EP - 61
JO - Seminars in Fetal and Neonatal Medicine
JF - Seminars in Fetal and Neonatal Medicine
SN - 1744-165X
IS - 1
ER -