Incidence and Root Cause Analysis of Wrong-site Pain Management Procedures
نویسندگان
چکیده
منابع مشابه
Wrong tooth extraction: root cause analysis.
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15 صفحه اولRoot Cause and Error Analysis
Error is an inevitable part of life and cannot be completely eliminated, but it can be minimized. A root cause analysis is a technique for understanding the systematic error causes that is involved beyond a person or people to implement an errors and including field and environmental causes of errors when occur in this situation too. An important factor of an error occurrence is a root cause (c...
متن کاملWrong-side thoracentesis: lessons learned from root cause analysis.
IMPORTANCE Despite the recognized value of the Joint Commission's Universal Protocol and the implementation of time-outs, incorrect surgical procedures are still among the most common types of sentinel events and can have fatal consequences. OBJECTIVES To examine a root cause analysis database for reported wrong-side thoracenteses and to determine the contributing factors associated with thei...
متن کاملIncidence, patterns, and prevention of wrong-site surgery.
HYPOTHESIS We hypothesized that wrong-site surgery is infrequent and that a substantial proportion of such incidents are not preventable by current site-verification protocols. DESIGN Case series and survey of site-verification protocols. SETTING Hospitals and a malpractice liability insurer. PATIENTS AND OTHER PARTICIPANTS All wrong-site surgery cases reported to a large malpractice insu...
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ژورنال
عنوان ژورنال: Anesthesiology
سال: 2010
ISSN: 0003-3022
DOI: 10.1097/aln.0b013e3181cf892d