Synopsis:
When a serious patient safety event (such as a sentinel event) occurs, it is critical for the health care organization to understand the system failures or defects that contributed to that event-and The Joint Commission requires a comprehensive systematic analysis be performed. Root cause analysis (RCA) provides such a systematic approach to identify those contributing factors, and it can also be used as a proactive tool to identify potential safety problems before they reach a patient. The 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. For ease of access and use by root cause analysis teams, practical checklists and worksheets are offered in each chapter. Root Cause Analysis in Health Care: Tools and Techniques, 6th edition, introduces this effective tool that can help health care organizations working to address a patient safety event, improve patient safety systems, or move toward high reliability to do the following: - Identify the processes that could benefit from root cause analysis - Decrease variation and defects (waste) - Ensure reliable processes - Achieve better outcomes - Determine effective and efficient ways of measuring and improving performance The sixth edition has been updated to address any changes related to The Joint Commission's Project REFRESH and carries through the fifth edition's revisions to Joint Commission standards and the Sentinel Event Policy.
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