How to perform a root cause analysis for workup and future prevention of medical errors: a review.
Providing quality patient care is a basic tenant of medical and surgical practice. Multiple orthopaedic programs, including The Patient Safety Committee of the American Academy of Orthopaedic Surgeons (AAOS), have been implemented to measure quality of surgical care, as well as reduce the incidence of medical errors. Structured Root Cause Analysis (RCA) has become a recent area of interest and, if performed thoroughly, has been shown to reduce surgical errors across many subspecialties. There is a paucity of literature on how the process of a RCA can be effectively implemented. The current review was designed to provide a structured approach on how to conduct a formal root cause analysis. Utilization of this methodology may be effective in the prevention of medical errors.
Department of Orthopaedic Surgery, University of Michigan, 2912 Taubman Center, SPC 5328, 1500 E. Medical Center Dr., Ann Arbor, MI 48109 USA.
Ryan
R
Charles
Department of Orthopaedic Surgery, University of Michigan, 2912 Taubman Center, SPC 5328, 1500 E. Medical Center Dr., Ann Arbor, MI 48109 USA.
Brandon
B
Hood
Center for Healthcare Engineering & Patient Safety, College of Engineering, University of Michigan, Ann Arbor, MI USA.
Joseph M
JM
Derosier
Department of Internal Medicine, University of Michigan, Ann Arbor, MI USA ; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI USA.
John W
JW
Gosbee
Department of Orthopaedic Surgery, University of Michigan, 2912 Taubman Center, SPC 5328, 1500 E. Medical Center Dr., Ann Arbor, MI 48109 USA.
Ying
Y
Li
Department of Orthopaedic Surgery, University of Michigan, 2912 Taubman Center, SPC 5328, 1500 E. Medical Center Dr., Ann Arbor, MI 48109 USA.
Michelle S
MS
Caird
Department of Orthopaedic Surgery, University of Michigan, 2912 Taubman Center, SPC 5328, 1500 E. Medical Center Dr., Ann Arbor, MI 48109 USA.
J Sybil
JS
Biermann
Department of Orthopaedic Surgery, University of Michigan, 2912 Taubman Center, SPC 5328, 1500 E. Medical Center Dr., Ann Arbor, MI 48109 USA.
Mark E
ME
Hake
Adverse events; Medical errors; Patient safety; Quality improvement; Resident education; Root cause analysis
Qual Saf Health Care. 2002 Sep;11(3):266-9
12486993
JAMA. 2008 May 14;299(18):2197-9
18477787
Radiographics. 2008 Sep-Oct;28(5):1237-50
18603662
J Gastrointest Surg. 2012 Jan;16(1):89-102; discussion 102-3
22065319