商品簡介
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. 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 an action plan for improvement Key Features: A 21-step framework for conducting an effective RCA Checklists and worksheets for applying the framework Tools and techniques used in root cause analysis Case studies from the field Key Audience: Patient safety officers Accreditation and compliance managers Quality improvement staff Clinical department heads
