Sentinel events, serious reportable events, and root cause analysis.
Chen TC, Schein OD, Miller JW. JAMA Ophthalmol. 2015 Mar 5; [Epub ahead of print].
This commentary describes the importance of performing root cause analyses following sentinel events andnever events in order to identify factors that contribute to failure and develop solutions to reduce risks. The authors use ophthalmologic examples to illustrate the elements of a systematic approach to root cause analysis following a never event, along with recommendations for organizations to consider to determine improvement strategies.
Unexpected hypoglycemia in a critically ill patient.
Bates DW. Ann Intern Med. 2002;137:110-116.
Adverse Health Events in Minnesota: Eleventh Annual Public Report.
St. Paul, MN: Minnesota Department of Health; February 2015.
Medication errors in the outpatient setting: classification and root cause analysis.
Friedman AL, Geoghegan SR, Sowers NM, Kulkarni S, Formica RN Jr. Arch Surg. 2007;142:278-283.
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Improving heparin safety: a multidisciplinary invited conference.
Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.
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