AHRQ Patient Safety Network: Learning from preventable deaths: exploring case record reviewers' narratives using change analysis.

AHRQ Patient Safety Network



Learning from preventable deaths: exploring case record reviewers' narratives using change analysis.

Hogan H, Healey F, Neale G, Thomson R, Black N, Vincent C. J R Soc Med. 2014;107:365-375.

Researchers applied change analysis, a type of root cause analysis, to their review of preventable deaths. This method reliably identified contributing factors and enabled more in-depth understanding about underlying problems related to care processes, lending support to utilizing this approach to characterize adverse events and near misses.

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