Making sense of root cause analysis investigations of surgery-related adverse events.

Cassin, BR; Barach, PR

Making sense of root cause analysis investigations of surgery-related adverse events.

Cassin, BR Barach, PR

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Publication Type:: Journal Article
Citation:: Surg Clin North Am, 2012, 92 (1), pp. 101 - 115
Issue Date:: 2012-02

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Field	Value	Language
dc.contributor.author	Cassin, BR	en_US
dc.contributor.author	Barach, PR	en_US
dc.date.issued	2012-02	en_US
dc.identifier.citation	Surg Clin North Am, 2012, 92 (1), pp. 101 - 115	en_US
dc.identifier.uri	http://hdl.handle.net/10453/30708
dc.description.abstract	This article discusses the limitations of root cause analysis (RCA) for surgical adverse events. Making sense of adverse events involves an appreciation of the unique features in a problematic situation, which resist generalization to other contexts. The top priority of adverse event investigations must be to inform the design of systems that help clinicians to adapt and respond effectively in real time to undesirable combinations of design, performance, and circumstance. RCAs can create opportunities in the clinical workplace for clinicians to reflect on local barriers and identify enablers of safe and reliable outcomes.	en_US
dc.language	eng	en_US
dc.relation.ispartof	Surg Clin North Am	en_US
dc.relation.isbasedon	10.1016/j.suc.2011.12.008	en_US
dc.subject.classification	Surgery	en_US
dc.subject.mesh	Humans	en_US
dc.subject.mesh	Surgical Procedures, Operative	en_US
dc.subject.mesh	Patient Safety	en_US
dc.subject.mesh	Root Cause Analysis	en_US
dc.title	Making sense of root cause analysis investigations of surgery-related adverse events.	en_US
dc.type	Journal Article
utslib.citation.volume	1	en_US
utslib.citation.volume	92	en_US
utslib.location.activity	United States	en_US
utslib.for	1103 Clinical Sciences	en_US
pubs.embargo.period	Not known	en_US
pubs.organisational-group	/University of Technology Sydney
pubs.organisational-group	/University of Technology Sydney/Faculty of Design, Architecture and Building
pubs.organisational-group	/University of Technology Sydney/Faculty of Design, Architecture and Building/School of Built Environment
utslib.copyright.status	closed_access
pubs.issue	1	en_US
pubs.publication-status	Published	en_US
pubs.volume	92	en_US

Abstract:

This article discusses the limitations of root cause analysis (RCA) for surgical adverse events. Making sense of adverse events involves an appreciation of the unique features in a problematic situation, which resist generalization to other contexts. The top priority of adverse event investigations must be to inform the design of systems that help clinicians to adapt and respond effectively in real time to undesirable combinations of design, performance, and circumstance. RCAs can create opportunities in the clinical workplace for clinicians to reflect on local barriers and identify enablers of safe and reliable outcomes.

Please use this identifier to cite or link to this item:

http://hdl.handle.net/10453/30708