Must Reads (June 26, 2015)

When something goes wrong, get it right!

To make sure that procedures are done correctly, this week’s must reads focus on:

    • Ensuring root cause analysis is done correctly.
    • Using anticoagulants properly.
    • Reducing patient falls.

Improving Root Cause Analyses and Actions to Prevent Harm

The National Patient Safety Foundation (NPSF) points out that root cause analysis is a process widely used by health professionals to learn how and why errors occurred, but there have been inconsistencies in the success of these initiatives.

For more on root cause analysis, see
For more on root cause analysis, see

To help develop an improved process for root cause analysis, NPSF recently issued its report, “RCA2: Improving Root Cause Analyses and Actions to Prevent Harm”, in which it concludes:

The key to establishing a successful root cause analysis and action process lies in leader- ship support. The components of a successful program include establishing a transparent risk-based methodology for triaging events, selecting the correct personnel to serve on the team, providing the team with the resources and time to complete the review, identifying at least one stronger or intermediate strength action in each review, and measuring the actions to assess if they were effective in mitigating the risk. Using tools such as risk-based prioritization matrices, Triggering Questions, the Five Rules of Causation, and the Action Hierarchy will aid the team in identifying and communicating causal factors and taking actions that will improve patient care and safety.

For examples and discussion of root cause analysis conducted by:

  • The VA National Center for Patient Safety, please see this interview with Bryanne Patail, biomedical engineer at the U.S. Department of Veterans Affairs, National Center for Patient Safety.
  • The California Department of Public Health, please click here.

Common Errors and Risk Reduction Strategies for Using Oral Anticoagulants

The Pennsylvania Patient Safety Authority recently issued an advisory on the use of oral anticoagulants, saying:

Oral anticoagulants have been identified as one of the most commonly implicated drug classes in adverse drug events. In fact, anticoagulants and cardiovascular agents, when compared with other medications, are more likely to cause potentially preventable adverse events that result in or prolong hospital stays.

We would also suggest assessing patients for the risk of blood clots, such as that used to assess:

Reducing Patient Falls

According to the Agency for Healthcare Research and Quality, about one million patients fall in the hospital each year.

Some healthcare facilities have successfully prevented patient falls. To read about two such hospitals, please click here.

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