Using fault trees to advance understanding of diagnostic errors. | AHRQ Patient Safety Network

Using fault trees to advance understanding of diagnostic errors. | AHRQ Patient Safety Network

• Commentary
 
• Published October 2017

Using fault trees to advance understanding of diagnostic errors.

Rogith D, Iyengar SM, Singh H. Jt Comm J Qual Patient Saf. 2017;43:598-605.

In-depth investigation of complicated processes can uncover underlying weaknesses that contribute to failure. This commentary describes how a project utilized fault-tree analysis as a method to examine elements that lead to diagnostic error.

PubMed citationAvailable at

Related Resources

JOURNAL ARTICLE › STUDY

Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences.

Stahel PF, Sabel AL, Victoroff MS, et al. Arch Surg. 2010;145:978-984.

JOURNAL ARTICLE › STUDY

Application of root cause analysis on malpractice claim files related to diagnostic failures.

van Noord I, Eikens MP, Hamersma AM, de Bruijne MC. Qual Saf Health Care 2010;19:e21.

MEETING/CONFERENCE › UPCOMING MEETING/CONFERENCE

Root Cause Analysis and Actions (RCA2).

Institute for Healthcare Improvement. January 10--March 21, 2018; Noon–1:00 PM (Eastern).

JOURNAL ARTICLE › STUDY

Root cause analysis of ICU adverse events in the Veterans Health Administration.

Corwin GS, Mills PD, Shanawani H, Hemphill RR. Jt Comm J Qual Patient Saf. 2017;43:580–590.

JOURNAL ARTICLE › STUDY

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].

View More