title: Fault Tree Analysis.
abstract: The purpose of this study was to use fault tree analysis to evaluate the adequacy of quality reporting programs in identifying root causes of postoperative bloodstream infection (BSI). A systematic review of the literature was used to construct a fault tree to evaluate 3 postoperative BSI reporting programs: National Surgical Quality Improvement Program (NSQIP), Centers for Medicare and Medicaid Services (CMS), and The Joint Commission (JC). The literature review revealed 699 eligible publications, 90 of which were used to create the fault tree containing 105 faults. A total of 14 identified faults are currently mandated for reporting to NSQIP, 5 to CMS, and 3 to JC; 2 or more programs require 4 identified faults. The fault tree identifies numerous contributing faults to postoperative BSI and reveals substantial variation in the requirements and ability of national quality data reporting programs to capture these potential faults. Efforts to prevent postoperative BSI require more comprehensive data collection to identify the root causes and develop high-reliability improvement strategies.
authors.affiliation: 1 Northwestern University, Chicago, IL.
authors.forename: Lisa M
authors.initials: LM
authors.lastname: McElroy
authors.affiliation: 1 Northwestern University, Chicago, IL.
authors.forename: Rebeca
authors.initials: R
authors.lastname: Khorzad
authors.affiliation: 1 Northwestern University, Chicago, IL.
authors.forename: Theresa A
authors.initials: TA
authors.lastname: Rowe
authors.affiliation: 1 Northwestern University, Chicago, IL.
authors.forename: Zachary A
authors.initials: ZA
authors.lastname: Abecassis
authors.affiliation: 1 Northwestern University, Chicago, IL.
authors.forename: Daniel W
authors.initials: DW
authors.lastname: Apley
authors.affiliation: 1 Northwestern University, Chicago, IL.
authors.forename: Cynthia
authors.initials: C
authors.lastname: Barnard
authors.affiliation: 1 Northwestern University, Chicago, IL.
authors.forename: Jane L
authors.initials: JL
authors.lastname: Holl
mesh_terms: D016470:Bacteremia / Q000209:etiology*; D003428:Cross Infection / Q000209:etiology*; D006801:Humans; D011183:Postoperative Complications / Q000209:etiology*; D058996:Quality Improvement / Q000458:organization & administration*; D019984:Quality Indicators, Health Care; D015203:Reproducibility of Results; D014481:United States
keywords: bloodstream infection; data collection; quality improvement; quality metrics; root cause analysis