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Data collection methods included observations at all study units, qualitative interviews, process mapping, root cause analyses of hospital readmissions, and focus groups with patients and caregivers.
The authors obtained and analyzed multiple types of qualitative data about this incident including interviews with KP staff, incident reports, root cause analyses, and media reports.
Identification of the time when a change manifests itself into the process, referred to as the change point, can help process engineers to perform root cause analyses effectively.
We expect that our skeptical mindset and skeptical attitude theoretical approach will move the literature forward, especially in terms of framing standards, developing interventions to improve audit quality, and performing root cause analyses.
Performing root cause analyses (RCA) on transfers of skilled nursing facility (SNF) patients to acute hospitals can help identify opportunities for care process improvements and education that may help prevent unnecessary emergency department (ED) visits, hospitalizations, and hospital readmissions.
I have been in a lot of root cause analyses in my career.
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Previously, the standard approach to its risk management process included monitoring business assets and conducting root-cause analyses on truck accidents after the fact.
This study – the first thorough evaluation of the confounding effects of benzyl alcohol on the ATT – was conducted in relation to particular health authority questions and was part of the root-cause analyses resulting from some transient behavioral findings observed in the test.
The authors designed an M&M involving clinical and non-clinical staff in conducting root-cause analyses of healthcare delivery at their hospital.
A ten-level dosimetric and medical severity scale were used to reflect the observed or estimated harm to a patient and a radiation oncology-specific root causes table was used to facilitate the root-cause analyses.
However, for a more comprehensive assessment of safety, other methods also need to be used, including reporting and learning systems, root-cause analyses, failure mode effects analyzes and morbidity and mortality reviews [ 13, 33].
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