title: Systematic root cause analysis of adverse drug events in a tertiary referral hospital.
abstract: BACKGROUND
  Adverse drug events (ADEs) occur frequently, and serious ADEs are associated with mortality or prolonged morbidity. As many ADEs are preventable, identification and modification of systems and processes that permit ADEs has the potential to reduce the rate of ADEs.
  
  
  METHODS
  Root cause analysis was systematically employed in a blame-free fashion to investigate the patterns of serious ADEs that occurred during a 29-month period at Hermann Hospital (Houston), and process improvements were implemented on the basis of these findings. The consistently nonpunitive responses to the results of the initial and subsequent root cause analyses was gradually seen, accepted, and ultimately embraced by the hospital staff.
  
  
  RESULTS
  The most commonly identified root causes were environmental factors (for example, increased census, increased acuity, change of shift) and staffing issues (for example, personnel new to a unit). Policy changes that led to increased use of forcing or constraining functions (for example, removal of concentrated intravenous potassium solutions from floor stocks) and better personnel support (for example, early awareness and response to localized increases in census and acuity) were particularly effective. Although limited by our lack of active surveillance and not necessarily directly due to the process changes that we implemented, the rate of voluntarily reported serious ADEs/100,000 patient days decreased during this time from 7.2 to 4.0, a decline of 45% (p < 0.001).
  
  
  CONCLUSIONS
  Systematic application of root cause analysis followed by implementation of process changes that target the underlying cause(s) of each event can be successfully implemented in a large hospital.
authors.affiliation: Hermann Hospital, Houston, TX, USA. jrex@heart.med.uth.tmc.edu
authors.forename: J H
authors.initials: JH
authors.lastname: Rex
authors.forename: J E
authors.initials: JE
authors.lastname: Turnbull
authors.forename: S J
authors.initials: SJ
authors.lastname: Allen
authors.forename: K
authors.initials: K
authors.lastname: Vande Voorde
authors.forename: K
authors.initials: K
authors.lastname: Luther
mesh_terms: D016907:Adverse Drug Reaction Reporting Systems; D002648:Child; D003953:Diagnosis-Related Groups; D064420:Drug-Related Side Effects and Adverse Reactions; D005500:Follow-Up Studies; D006776:Hospitals, Pediatric; D006801:Humans; D007902:Length of Stay; D008508:Medication Errors; D008510:Medication Systems, Hospital / Q000592:standards; D011787:Quality of Health Care; D012017:Referral and Consultation; D012307:Risk Factors; D012449:Safety; D013781:Texas; D013997:Time Factors