Root_Cause_Analysis

Root_Cause_Analysis - Root Cause Analysis Vic V Vernenkar...

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Root Cause Analysis Vic V. Vernenkar, D.O. St. Barnabas Hospital Department of Surgery
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JCAHO Alerts in 2001: Patients catching on fire. Deaths due to mix-up of gases. Disease transmission through surgical instruments. Transmission of blood borne pathogens through needle sticks. Wrong side/wrong procedure/wrong person surgeries.
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All locations vulnerable: Hospital-based ambulatory care units. Freestanding ambulatory care units. Inpatient operating rooms. Inpatient emergency rooms. In-home care.
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Complex Systems Diagnosis Treatment Patient tracking Facility maintenance Equipment operation Controlled Substances
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Adverse and Sentinel Events “Unintended injury to patients resulting from a medical intervention, which includes any action by healthcare workers, including clerical and maintenance staff.” Institute of Medicine “An unexpected occurrence involving death or serious physical or psychological injury or risk thereof.” Joint Commission
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Immediate Causes: Deviations between what should occur and what actually occurred. The immediate cause may be disguised by complexity of events. Important to be able to ask diagnostic questions: what, where, when, extent, is and is not.
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A root cause is the most basic causal factor, or factors , which if corrected or removed will prevent the recurrence of a situation, such as an error in performing a procedure. Root causes create the setting for immediate causes of problems. Analysis is an investigative technique that allows organizations to identify retrospectively the reasons why certain outcomes occurred. Oversimplification!
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This note was uploaded on 12/27/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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Root_Cause_Analysis - Root Cause Analysis Vic V Vernenkar...

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