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Showing results for tags 'Root cause anaylsis'.
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Content Article“Failure to rescue” (FTR) is the failure to prevent a death resulting from a complication of medical care or from a complication of underlying illness or surgery. There is a growing body of evidence that identifies causes and interventions that may improve institutional FTR rates. Why do patients “fail to rescue” after complications in hospital? What clinically relevant interventions have been shown to improve organisational fail to rescue rates? Can successful rescue methods be classified into a simple strategy?
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- Deterioration
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Content ArticleCause and effect is a diagram-based technique that helps you identify all of the likely causes of the problems you're facing.
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Content ArticleThis diagram, published by the Institute for Healthcare Improvement (IHI), is titled A driver diagram to systematically and proactively identify and eliminate non-value-added waste in the US health care system by 2025. Produced by the IHI's Leadership Alliance's Waste Working Group, it sets out a number of drivers for reducing waste in the healthcare system in America. The top driver listed focuses on safety and reducing harm.
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- Quality improvement
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Content ArticleAt a time of increasing regulatory scrutiny and medico-legal risk, managing serious clinical incidents within primary care has never been more important. Failure to manage appropriately can have serious consequences both for service organisations and for individuals involved. This is the first book to provide detailed guidance on how to conduct incident investigations in primary care. The concise guide: explains how to recognise a serious clinical incident, how to conduct a root cause analysis investigation, and how and when duty of candour applies covers the technical aspects of serious incident recognition and report writing includes a wealth of practical advice and 'top tips', including how to manage the common pitfalls in writing reports offers practical advice as well as some new and innovative tools to help make the RCA process easier to follow explores the all-important human factors in clinical incidents in detail, with multiple examples and worked-through cases studies as well as in-depth sample reports and analysis. This book offers a master class for anyone performing root cause analysis and aiming to demonstrate learning and service improvement in response to serious clinical incidents. It is essential reading for any clinical or governance leads in primary care, including GP practices, 'out-of-hours', urgent care centres, prison health and NHS 111. It also offers valuable insights to any clinician who is in training or working at the coal face who wishes to understand how serious clinical are investigated and managed.
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- Investigation
- Legal issue
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Content ArticleWhile a recognised and accepted investigation process, barriers exist to the effective use of root cause analysis and implementation of improvements identified to generate sustainable action. This article lists tools identified by a literature review that sought to highlight incident review alternatives to RCAs, with particular focus on low-harm or no-harm events that should be examined to minimise their potential for contributing to patient harm.
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Content ArticleWhen patients are harmed as a result of the care they receive through Alberta Health Services (AHS), the organisation has a responsibility to understand how the harm happened and, where appropriate, respond to improve the healthcare system. This handbook has been developed to assist and support AHS staff and medical staff to retrospectively review clinical adverse events, hazards and close calls using Systems Analysis Methodologies (SAM). It is not an administrative review of individual healthcare provider performance. Using these methodologies, the complex interactions of all the components within the health system are considered, not the individual contributions of healthcare providers that have or may have led to harm. This creates opportunities to identify vulnerabilities in structures, processes and practices that can be improved and ultimately make care safer.
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- Patient death
- Patient harmed
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Content ArticleA new study published in the December 2019 issue of The Joint Commission Journal on Quality and Patient Safety details a quality improvement project by researchers at Penn Medicine, Philadelphia, USA, to reduce the risk of single-patient insulin pens. Insulin pens are widely used in hospitals because they have multiple safety advantages compared to insulin vials, including a product name and barcode and a dial mechanism for less error-prone dosing. Despite these features, accidental sharing of pens still occurs, putting patients at risk for exposure to HIV, hepatitis B virus or hepatitis C virus.
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- Root cause anaylsis
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Content ArticleAccident investigations should consider why human failures occurred. Finding the underlying (or latent, root) causes is the key to preventing similar accidents.
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- Human error
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Content ArticleThis policy confirms the process for reviewing deaths within Lincolnshire Community Health Services (LCHS) to ensure a consistent approach is followed in order to identify if the patient’s needs were met during the end of life phase and that relatives and carers were supported appropriately. The aim of the mortality review process is to identify any areas of practice that require improvement and to identify areas of good practice. This process ensures that mortality within LCHS is managed and reviewed in a systematic way.
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- Patient death
- Organisational learning
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Content Article
Failure - is it a matter of when?
Claire Cox posted an article in Miscellaneous
'When problems occur we hunt for a single root cause, that one broken piece or person to hold accountable. Our analyses of complex system breakdowns remains linear, componential and reductive.' This is evident in healthcare. Barry O’Reilly is a business advisor, entrepreneur and author who has pioneered the intersection of business model innovation, product development, organisational design and culture transformation. In this blog he discusses the 'drift into failure', i.e. we had the warning signs but accepted them as the norm.- Posted
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Content ArticleROSPA's one-day accident investigation training will give you a broad understanding of the accident investigation process, looking at the benefits of accident prevention and putting the emphasis on practical training exercises and real-life case studies. Training is suitable for line managers, supervisors, safety representatives – and anyone with the responsibility for investigating accidents. It will enable organisations to meet their moral and legal obligations to investigate accidents and incidents and learn from safety failure.
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Content ArticleNEBOSH and Great Britain’s Health and Safety Regulator, the Health and Safety Executive (HSE), have jointly developed a new one day qualification that shows how non-complex incidents can be investigated effectively. By learning lessons and making improvements, organisations can avoid similar incidents occurring in the future.
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- Investigation
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Content ArticleThis is a comprehensive collection of proven quality, service improvement and redesign tools, theories and techniques that can be applied to a wide variety of situations. You can search the collection alphabetically for a specific tool or browse groups of tools using one of four categories.
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- Root cause anaylsis
- Quality improvement
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Content ArticleBy repeatedly asking the question ‘why?’ (use five as a rule of thumb), you can peel away the layers of a problem to get to the root cause. Five whys can help you determine the relationship between different root causes of a problem. It is a simple tool and can be completed without statistical analysis. You can use this tool either in isolation or to complement a root cause analysis. Because it quickly helps identify the source of an issue or problem, you can focus resources in the correct areas and ensure you are tackling the true cause of the problem, not just its symptoms.
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Content Article
The problem with ‘5 whys’ (September 2017)
Claire Cox posted an article in Quality Improvement
‘The problem with…’ series, from the BMJ Quality & Safety, covers controversial topics related to efforts to improve healthcare quality, including widely recommended but deceptively difficult strategies for improvement and pervasive problems that seem to resist solution. The ‘5 whys’ technique is one of the most widely taught approaches to root-cause analysis (RCA) in healthcare. Its use is promoted by the WHO, the English National Health Service, the Institute for Healthcare Improvement, the Joint Commission and many other organisations in the field of healthcare quality and safety. Like most such tools, though, its popularity is not the result of any evidence that it is effective. This article argues that healthcare is complex and why finding the solution via the 5 whys should be abandoned. -
Content ArticlePresentation from WHO's 'A Decade of Patient Safety 2020-2030: Formulating Global Patient Safety Action Plan' patient safety meeting in Geneva.
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- Safety culture
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Content ArticleIn this BMJ Opinion article, David Rowland from the Centre for Health and the Public Interest discusses why he thinks the Independent Inquiry into the issues raised by Paterson is yet another missed opportunity to tackle the systemic patient safety risks which lie at the heart of the private hospital business model. David believes that although the Inquiry provided an important opportunity for the hundreds of patients affected to bear witness to the pain and harm inflicted upon them it fundamentally failed as an exercise in root cause analysis. None of the “learning points” in the final report touch on the financial incentives which may have led Paterson to deliberately over treat patients. Nor do they cover the business reasons which might encourage a private hospital’s management not to look too closely. Yet these concerns about how the private hospital system works and the associated patient risks it produces had been established in a number of previous inquiries. He suggests that the Inquiry report threw the responsibility for managing patient safety risks back to the patients themselves in two of its main recommendations but that it should be for the healthcare provider first and foremost to ensure that the professions that they employ are safe, competent and properly supervised, and for this form of assurance to be underpinned by a well-functioning system of licensing and revalidation by national regulatory bodies.
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- Private sector
- Surgeon
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Content ArticleAn examination of how humans interact with their environments and each other led this team to question one of its long-standing medication safety practices and change how they work.
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- Human factors
- Paediatrics
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Content ArticleIn this blog, Jessica Behrhorst, Senior Director for Patient Safety at the Institute for Healthcare Improvement (IHI), discusses challenges staff face in creating a safety culture, such as fear of negative consequences and thinking they will not be taken seriously. She highlights the importance of acknowledging these fears and building positive group norms in order to engage staff. She also highlights the role of root cause analysis in addressing fears about speaking up.
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- Speaking up
- Safety culture
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