Root cause analysis following nephrectomy after extracorporeal shockwave lithotripsy (ESWL).
An adverse event after a routine extracorporeal shockwave lithotripsy procedure set into motion a root cause analysis methodology to decipher why and how the event occurred and offer a solution to prevent it from happening again. The process of performing a root cause analysis is discussed in detail.
Cahill
Katie
K
Cruz
Eneida
E
Guilbert
Mary Beth
MB
Oser
Meg O'Toole
MO
D000368:Aged; D015984:Causality; D003142:Communication; D003625:Data Collection; D003627:Data Interpretation, Statistical; D006470:Hemorrhage / Q000209:etiology / Q000601:surgery; D006801:Humans; D007668:Kidney / Q000293:injuries; D008096:Lithotripsy / Q000009:adverse effects; D008297:Male; D019300:Medical Errors / Q000379:methods / Q000517:prevention & control; D017146:Models, Organizational; D009392:Nephrectomy; D009936:Organizational Innovation; D016134:Organizational Policy; D010043:Outcome and Process Assessment, Health Care / Q000458:organization & administration*; D024382:Professional Role; D018570:Risk Assessment; D040242:Risk Reduction Behavior; D013597:Systems Analysis; D017749:Total Quality Management / Q000458:organization & administration*