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This folder contains information and materials you will need to complete the Root Cause Analysis assignment for this module.
Gilbert, R. E. (2016). The Human Factor: Designing Safety into Oncology Practice. Journal of Oncology Practice, 12(10), 884–887. https://doi.org/10.1200/JOP.2016.013045
Read and review the Gilbert article which relays the details of a sentinel event that resulted in the death of a patient. Sixteen causal factors were identified. The author outlines some of the system failures and human errors that occurred in this sentinel event.
Using the information in the article, develop your Root Cause Analysis using the Fishbone Framework template provided
In a separate sheet describe your findings (analysis) and provide recommendations using the six IOM domains of quality in Module 1.
Required Textbook Readings:
Spath, P. (Ed.). (2018). Improving patient safety. In Introduction to Health Care Quality Management (3rd ed). Health Administration Press. (Chapter 8: pp. 193-222).
Required Articles Readings:
Gilbert, R. E. (2016). The Human Factor: Designing Safety Into Oncology Practice. Journal of Oncology Practice, 12(10), 884–887. https://doi.org/10.1200/JOP.2016.013045
Hooker, A. B., Etman, A., Westra, M., kam, W. J. V. der, & Van der Kam, W. J. (2019). Aggregate analysis of sentinel events as a strategic tool in safety management can contribute to the improvement of healthcare safety. International Journal for Quality in Health Care, 31(2), 110–116. https://doi.org/10.1093/intqhc/mzy116 https://academic.oup.com/intqhc/article/31/2/110/4999737
Recommended Supplemental Websites and Articles:
The Joint Commission (TJC). (2021) Sentinel Event Policy. Available online at: http://www.jointcommission.org/Sentinel_Event_Policy_and_Procedures/
AHRQ Patient Safety Network. (2021) Approach to Improving Patient Safety: Communication https://psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
AHRQ Patient Safety Network. (2019) Root Cause Analysis. Retrieved from; http://psnet.ahrq.gov/primer.aspx?primerID=10
AHRQ Patient Safety Network. (2019) Systems Approach. Retrieved from; http://psnet.ahrq.gov/primer.aspx?primerID=21
https://youtu.be/QexTk38euzY (6 health care quality dimensions)