Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons learned. | AHRQ Patient Safety Network

Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons learned. | AHRQ Patient Safety Network

• Study
 
• Published June 2017

Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons learned.

Neily J, Silla ES, Sum-Ping SJT, et al. Anesth Analg. 2017 Jul 1; [Epub ahead of print].

This study examined root cause analyses performed by the Veterans Health Administration to identify and characterize anesthesia-related safety events. Although a relatively small number of events were found, the authors identified several human factors solutions that, if implemented, could prevent common types of errors.

PubMed citationAvailable at

Related Resources

JOURNAL ARTICLE › STUDY

Root cause analysis of ambulatory adverse drug events that present to the emergency department.

Gertler SA, Coralic Z, López A, Stein JC, Sarkar U. J Patient Saf. 2016;12:119-124

JOURNAL ARTICLE › STUDY

What’s past is prologue: organizational learning from a serious patient injury.

Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.

NEWSPAPER/MAGAZINE ARTICLE

Building patient safety skills: common pitfalls when conducting a root cause analysis.

ISMP Medication Safety Alert! Acute Care Edition. April 22, 2010;15:1-4.

JOURNAL ARTICLE › COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:547-550, 554.

JOURNAL ARTICLE › STUDY

Effective interventions and implementation strategies to reduce adverse drug events in the Veterans Affairs (VA) system.

Mills PD, Neily J, Kinney LM, Bagian J, Weeks WB. Qual Saf Health Care. 2008;17:37-46.

JOURNAL ARTICLE › STUDY

Follow-up study of medication errors reported to the Vaccine Adverse Event Reporting System (VAERS).

Varricchio F, Reed J, and the VAERS Working Group. South Med J. 2006;99:486-489.

PATIENT SAFETY PRIMER

Root Cause Analysis

JOURNAL ARTICLE › COMMENTARY

Investigating the causes of adverse events.

Sanchez JA, Lobdell KW, Moffatt-Bruce SD, Fann JI. Ann Thorac Surg. 2017;103:1693-1699.

JOURNAL ARTICLE › STUDY

Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports.

Riblet N, Shiner B, Watts BV, Mills P, Rusch B, Hemphill RR. J Nerv Ment Dis. 2017;205:436-442.

JOURNAL ARTICLE › COMMENTARY

Root cause analysis and actions for the prevention of medical errors: quality improvement and resident education.

Charles R, Hood B, DeRosier JM, et al. Orthopedics. 2017;40:e628-e635.

JOURNAL ARTICLE › STUDY

Root cause analysis of adverse events in an outpatient anticoagulation management consortium.

Graves CM, Haymart B, Kline-Rogers E, et al. Jt Comm J Qual Patient Saf. 2017;43:299-307.

JOURNAL ARTICLE › COMMENTARY

Root-cause analysis: swatting at mosquitoes versus draining the swamp.

Trbovich P, Shojania KG. BMJ Qual Saf. 2017;26:350-353.

BOOK/REPORT

Patient Safety: Investigating and Reporting Serious Clinical Incidents.

Kelsey R. CRC Press: Boca Raton, FL; 2017. ISBN: 9781498781169.

BOOK/REPORT

Adverse Health Events in Minnesota: 13th Annual Public Report.

St. Paul, MN: Minnesota Department of Health; February 2017.

JOURNAL ARTICLE › COMMENTARY

Management of a patient with a latex allergy.

Minami CA, Barnard C, Bilimoria KY. JAMA. 2017;317:309-310.

JOURNAL ARTICLE › STUDY

Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?

Kellogg KM, Hettinger Z, Shah M, et al. BMJ Qual Saf. 2017;26:381-387.

PERSPECTIVES ON SAFETY

Errors and Near Misses: What Health Care Could Learn From Aviation

Carl Macrae, PhD

PERSPECTIVES ON SAFETY

In Conversation With... James P. Bagian, MD, PE

JOURNAL ARTICLE › REVIEW

How to perform a root cause analysis for workup and future prevention of medical errors: a review.

Charles R, Hood B, Derosier JM, et al. Patient Saf Surg. 2016;10:20.

JOURNAL ARTICLE › COMMENTARY

The problem with the '5 whys.'

Card AJ. BMJ Qual Saf. 2017;26:671-677.

JOURNAL ARTICLE › STUDY

Delayed recognition of deterioration of patients in general wards is mostly caused by human related monitoring failures: a root cause analysis of unplanned ICU admissions.

van Galen LS, Struik PW, Driesen BEJM, et al. PLoS One. 2016;11:e0161393.

JOURNAL ARTICLE › COMMENTARY

The problem with root cause analysis.

Peerally MF, Carr S, Waring J, Dixon-Woods M. BMJ Qual Saf. 2017;26:417-422.

JOURNAL ARTICLE › STUDY

Unit-based incident reporting and root cause analysis: variation at three hospital unit types.

Wagner C, Merten H, Zwaan L, Lubberding S, Timmermans D, Smits M. BMJ Open. 2016;6:e011277.

JOURNAL ARTICLE › COMMENTARY

A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change.

Clifford SP, Mick PB, Derhake BM. J Investig Med High Impact Case Rep. 2016;4:2324709616647746.

JOURNAL ARTICLE › COMMENTARY

A new frontier in healthcare risk management: working to reduce avoidable patient suffering.

Card AJ, Klein VR. J Healthc Risk Manag. 2016;35:31-37.