title: [The experience of the Root Cause Analysis (RCA) regarding the adverse event "missing sample from the patient source"].
abstract: Creation of the Root Cause Analysis (RCA) represents a phase of     clinical risk management and is the instrument chosen for reactive     analysis of adverse events. It is important to consider RCA in the context     of the entire clinical risk management process and to understand the     interrelationships with the previous and subsequent phases, in order to     identify the necessary input and the expected output of such activity. In     this study the input consisted of the adverse event which occurred after a     health worker had been exposed to a biological risk and the "source     patient sample" could not be found. The hospital and nursing authorities     analyzed the event to understand its dynamics and causes. The results, or     output, obtained indicate the steps necessary to go on to the next phase,     namely treatment of the risk and the need for systemic measures:     improvement of communication , revision of hospital procedures for     managing blood samples and modification of the laboratory computer     programs.
authors: Funzione Aziendale Gestione del Rischio - AUSL Ravenna.
authors: Riccarda
authors: R
authors: Suprani
authors: Rosalba
authors: R
authors: Pellegrini
authors: Marialina
authors: M
authors: Vitullo
authors: Tulliio
authors: T
authors: Fabbri
authors: Marial Giulia
authors: MG
authors: Cimmati
mesh_terms: D006282:Health Personnel; D006801:Humans; D016273:Occupational Exposure; D060891:Root Cause Analysis; D017751:Safety Management