Random Safety Auditing, Root Cause Analysis, Failure Mode and Effects Analysis

被引:29
作者
Ursprung, Robert [1 ]
Gray, James [2 ,3 ]
机构
[1] Pediatrix Med Grp, Cook Childrens Med Ctr, Dept Neonatol, Ft Worth, TX 76104 USA
[2] Harvard Univ, Sch Med, Div Newborn Med, Cambridge, MA 02138 USA
[3] Beth Israel Deaconess Med Ctr, Div Clin Informat, Dept Neonatol, Boston, MA 02215 USA
关键词
Failure mode and effects analysis; Root cause analysis; Random safety auditing; ADVERSE DRUG EVENTS; INTENSIVE-CARE-UNIT; MEDICATION ERRORS; PATIENT SAFETY; HOSPITALIZED-PATIENTS; TRIGGER TOOL; QUALITY;
D O I
10.1016/j.clp.2010.01.008
中图分类号
R71 [妇产科学];
学科分类号
100211 ;
摘要
Improving quality and safety in health care is a major concern for health care providers, the general public, and policy makers. Errors and quality issues are leading causes of morbidity and mortality across the health care industry. There is evidence that patients in the neonatal intensive care unit (NICU) are at high risk for serious medical errors. To facilitate compliance with safe practices, many institutions have established quality-assurance monitoring procedures. Three techniques that have been found useful in the health care setting are failure mode and effects analysis, root cause analysis, and random safety auditing. When used together, these techniques are effective tools for system analysis and redesign focused on providing safe delivery of care in the complex NICU system.
引用
收藏
页码:141 / +
页数:26
相关论文
共 52 条
[41]   Adverse events in the neonatal intensive care unit: Development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs [J].
Sharek, Paul J. ;
Horbar, Jeffrey D. ;
Mason, Wilbert ;
Bisarya, Hema ;
Thurm, Cary W. ;
Suresh, Gautham ;
Gray, James E. ;
Edwards, William H. ;
Goldmann, Donald ;
Classen, David .
PEDIATRICS, 2006, 118 (04) :1332-1340
[42]   Reducing medication errors in the neonatal intensive care unit [J].
Simpson, JH ;
Lynch, R ;
Grant, J ;
Alroomi, L .
ARCHIVES OF DISEASE IN CHILDHOOD-FETAL AND NEONATAL EDITION, 2004, 89 (06) :F480-F482
[43]   Voluntary anonymous reporting of medical errors for neonatal intensive care [J].
Suresh, G ;
Horbar, JD ;
Plsek, P ;
Gray, J ;
Edwards, WH ;
Shiono, PH ;
Ursprung, R ;
Nickerson, J ;
Lucey, JF ;
Goldmann, D .
PEDIATRICS, 2004, 113 (06) :1609-1618
[44]  
TUNNER JR, 1990, QUALITY TECHNOLOGY P
[45]   Real time patient safety audits: improving safety every day [J].
Ursprung, R ;
Gray, JE ;
Edwards, WH ;
Horbar, JD ;
Nickerson, J ;
Plsek, P ;
Shiono, PH ;
Suresh, GK ;
Goldmann, DA .
QUALITY & SAFETY IN HEALTH CARE, 2005, 14 (04) :284-289
[46]  
URSPRUNG R, 2005, PED AC SOC ANN M WAS
[47]  
*US AG HEALTHC RES, 2001, MAK HLTH CAR SAF CRI
[48]   Adverse events in British hospitals: preliminary retrospective record review [J].
Vincent, C ;
Neale, G ;
Woloshynowych, M .
BRITISH MEDICAL JOURNAL, 2001, 322 (7285) :517-519
[49]  
Wilson P.F., 1993, ROOT CAUSE ANAL TOOL
[50]   Quality in Australian Health Care Study [J].
Wilson, RM ;
Runciman, WB ;
Gibberd, RW ;
Harrison, BT ;
Hamilton, JD .
MEDICAL JOURNAL OF AUSTRALIA, 1996, 164 (12) :754-754