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Root Cause Analysis in Health Care: Tools and Techniques, 6th Edition
All levels
U.S. Standards

Root Cause Analysis in Health Care: Tools and Techniques, 6th Edition

Address patient safety events head on and get help to further your understanding of root causes for errors!

Release Date: October 2017. 186 pages.

$89.00 - $219.00
Product Description

Product Description

When a serious patient safety event occurs, the health care organization must identify and examine the system failures or defects that contributed to the event to guard against future reoccurrences. Root cause analysis (RCA) provides a systematic approach to identify these contributing factors. In the specific case of a sentinel event, The Joint Commission requires accredited organizations to perform a comprehensive systematic analysis. However, RCA also can be used as a proactive tool to identify potential safety problems before they reach a patient. This book includes examples that guide the reader through application of root cause analysis to the investigation of specific types of sentinel events, such as medication errors, suicide, treatment delay, and elopement. 
 
Root Cause Analysis in Health Care: Tools and Techniques, 6th edition, provides updated statistics and introduces new concepts and tools associated with RCA2: Improving Root Cause Analyses and Actions to Prevent Harm, the National Patient Safety Foundation’s in-depth report focusing on the techniques and processes of how root cause analyses can best prioritize system flaws and vulnerabilities and make improvements to successfully improve patient care in all health care settings. This book also includes new and revised tools aligned with the Joint Commission’s Robust Process Improvement® (RPI®), a set of process improvement strategies adopted by The Joint Commission to help organizations improve business processes and clinical outcomes.
 
Key Topics:
  • Overview of root cause analysis and how it is used both proactively and as a response to a sentinel event
  • Addressing sentinel events in policy and practice
  • Preparing for a root cause analysis
  • Determining proximate and root causes
  • Designing and implementing a corrective action plan for improvement
Key Features:
  • A framework with 24 analysis questions for conducting an effective RCA
  • Checklists and worksheets for applying the framework
  • Tools and techniques used in root cause analysis
Key Audience:
  • Accreditation and compliance managers
  • Clinical department heads
  • Patient safety officers
  • Quality improvement staff
  • Risk managers
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Table of Contents

Table of Contents

Introduction        

 
Chapter 1: Root Cause Analysis: An Overview    
Investigating Patient Safety Events: The Need for Comprehensive Systematic Analysis 
RCA2 in High Reliability Industries
When Can a Root Cause Analysis Be Performed? 
Variation and the Difference Between Proximate and Root Causes 
Benefits of Root Cause Analysis 
Maximizing the Value of Root Cause Analysis 
The Root Cause Analysis and Corrective Action Plan: Doing It Right 
 
Chapter 2: Addressing Sentinel Events in Policy and Strategy 
The Range of Adverse Events in Health Care 
Signals of Risk: Close Calls and No Harm Events 
The Joint Commission’s Sentinel Event Policy 
Reasons for Reporting a Sentinel Event to The Joint Commission 
Required Response to a Sentinel Event 
Joint Commission International’s Sentinel Event Policy 
Related Joint Commission International Standards 
Developing Your Own Sentinel Event Policy 
Leadership, Culture, and Patient Safety Events 
Early Response Strategies 
Event Investigation 
Onward with Root Cause Analysis 
 
Chapter 3: Preparing for Root Cause Analysis 
Step 1 Organize a Team 
Step 2 Define the Problem 
Step 3 Study the Problem 
 
Chapter 4: Determining Proximate Causes 
Step 4 Determine What Happened 
Step 5 Identify Contributing Process Factors 
Step 6 Identify Other Contributing Factors 
Step 7 Measure—Collect and Assess Data on Proximate and Underlying Causes 
Step 8 Design and Implement Immediate Changes 
 
Chapter 5: Identifying Root Causes 
Step 9? Identify Which Systems Are Involved—The Root Causes 
Step 10 Prune the List of Root Causes 
Step 11 Confirm Root Causes and Consider Their Interrelationships 
 
Chapter 6: Designing and Implementing a Corrective Action Plan for Improvement 
Step 12 Explore and Identify Risk-Reduction Strategies 
Step 13 Formulate Improvement Actions 
Step 14 Evaluate Proposed Improvement Actions 
Step 15 Design Improvements 
Step 16 Ensure Acceptability of the Corrective Action Plan 
Step 17 Implement the Improvement Plan 
Step 18 Develop Measures of Effectiveness and Ensure Their Success 
Step 19 Evaluate Implementation of Improvement Efforts 
Step 20 Take Additional Action 
Step 21 Communicate the Results 
 
Chapter 7: Addressing Sentinel Events in Policy and Strategy 
What is RPI®?
What Is Lean Six Sigma? 
Affinity Diagram 
Brainstorming 
Change Analysis 
Change Management 
Check Sheet 
Control Chart 
Failure Mode and Effects Analysis (FMEA) 
Fishbone Diagram 
Flowchart 
Gantt Chart 
Histogram 
Multivoting 
Operational Definition 
Pareto Chart 
Relations Diagram 
Run Chart 
Scatter Diagram 
SIPOC Process Map 
Stakeholder Analysis 
Standard Work 
Value Stream Mapping 
 

Appendix

Glossary 

Index