title: Root cause analysis in infusion nursing: applying quality improvement tools for adverse events.
abstract: The application of root cause analysis (RCA) to health care began in the Veteran's Administration system and spread to Joint Commission-accredited organizations when it became a requirement for accreditation. The success of this valuable quality improvement tool relies on understanding the principles of patient safety, assembling a team, and producing and completing action items aimed at correcting root causes of adverse events. This article describes optimal RCA techniques based on published literature and expert opinion and then provides a sample RCA for a fictitious but common adverse event: catheter-associated bloodstream infection.
authors: Cadence Health, Winfield, Illinois. Rachel L. Zastrow, MSN, RN, CCRN, CPPS, LSSBB, is Director, Patient Safety, Advocate Lutheran General Hospital, Park Ridge, Illinois.
authors: Rachel L
authors: RL
authors: Zastrow
mesh_terms: D006801:Humans; D007263:Infusions, Parenteral / Q000451:nursing*; D019300:Medical Errors / Q000517:prevention & control; D010043:Outcome and Process Assessment, Health Care / Q000379:methods; D061214:Patient Safety; D058996:Quality Improvement; D060891:Root Cause Analysis; D014481:United States