title: How root-cause analysis can improve patient safety.
abstract: A key to improving patient safety and providing quality care is identifying, reporting, reviewing, and addressing the problems that are related to adverse events and close calls. A tool that has evolved to meet this need is the use of root-cause analysis (RCA). But can more be done with the RCA to make it work smoothly within a health care setting--while providing useful information in a timely manner that health care organizations can act upon? Staff at the Department of Veterans Affairs involved with patient safety think so. Last month, they discussed numerous initiatives--ranging from "triage cards" to redesigned software applications to redefined leadership roles--that are giving a new edge to using RCA effectively throughout the 170-plus VA health care facilities across the country.
authors.forename: J C
authors.initials: JC
authors.lastname: Simmons
mesh_terms: D006787:Hospitals, Veterans / Q000592:standards*; D006801:Humans; D007318:Inservice Training; D007324:Institutional Management Teams; D007857:Leadership; D019300:Medical Errors / Q000517:prevention & control*; D015279:Organizational Culture; D017064:Process Assessment, Health Care; D017751:Safety Management / Q000379:methods*; D012984:Software; D013597:Systems Analysis; D013997:Time Factors; D014218:Triage; D014481:United States; D014493:United States Department of Veterans Affairs