.... For the effective management of water resources, social and hydrological components should be studied. To fill this gap, the aim of this study was to investigate the socio-hydrological system of the Gavshan Dam in western Iran. Therefore, the qualitative method and root cause analysis (RCA) were used to investigate...

.... digital health COVID-19 COVID-19 vaccination data Africa root cause analysis data backlog Building on USAID’s preliminary analysis, this study aimed to identify the root causes of COVID-19 vaccination data backlogs in the Democratic Republic of the Congo (DRC), Kenya, Senegal and Tanzania...

...) to implement this model for plasma transferrin tests as an LUM strategy to reduce overutilization. TABLE 1 Five Steps of the Root Cause Analysis Model for Laboratory Test Overutilization Step of root cause analysis Tool 1. Describe the adverse event and ordering process Process flow diagram...

... and private hospitals within 48 h of discovery [ 7 ]. The system consists of a secure, web-based portal that allows hospitals to submit information about the type of SE, time, location, contributing factors, subsequent patient outcome and impact on patient care. It also includes a root cause analysis (RCA...

... the fix cut across multiple levels of the organization?’ and (d) ‘degree’, ‘Does the fix reflect a fundamental shift in the way the organization operates?’ patient safety systems change root cause analysis active failures latent conditions [A]ctive failures are like mosquitos. They can be swatted one...

... and distributed under the terms of the Oxford University Press, Standard Journals Publication Model ( https://dbpia.nl.go.kr/journals/pages/open_access/funder_policies/chorus/standard_publication_model ) Abstract Objectives Conduct a secondary analysis of root cause analysis (RCA) reports of Never Events...

... and compromise the quality of care or affect the safety of the health care consumer. Even though incident reporting, root cause analysis, use of checklists and other quality improvement methods are in wide-spread use, we may not be using these tools appropriately and therefore we are losing an opportunity...

... within three and seven days that were also reported in Root Cause Analysis reports*. NDI = National Death Index; RCA = Root Cause Analysis. *Includes suicides reported within three days and seven days of discharge from any Veterans Affairs inpatient mental health unit. 02 01 2019 06 02 2019 23...

... their institution’s capacity for organisational learning and continuous improvement. safety culture cluster trials healthcare quality improvement root cause analysis risk management According to the European Society for Quality in Health Care, safety culture is defined as ‘An integrated pattern of individual...

... This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model ( https://dbpia.nl.go.kr/journals/pages/open_access/funder_policies/chorus/standard_publication_model ) root cause analysis adverse events quality of healthcare incident reporting...

... settings. Aim statement Spaghetti diagram Fishbone and root cause analysis Counterbalance measure Plan-Do-Study-Act (PDSA) cycle Quality improvement project (QIP) The layout and design of a workspace influence the productivity of workgroups, including those in health care environments. ¹...

... is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model ( https://dbpia.nl.go.kr/journals/pages/about_us/legal/notices ) Abstract Objective To assess the strength of root cause analysis (RCA) recommendations and their perceived levels...

... of conducting investigation of the causality of adverse surgical outcomes. Design Six hundred and thirty-one closed claims of a major medical malpractice insurance company were reviewed. Each case had undergone conventional root cause analysis (RCA). Claims were categorized by comparing the predominant...

...Robert L. Schmidt; Bonnie L. Messinger; Lester J. Layfield specimen labeling root cause analysis surgical pathology quality management errors error classification The elimination of medical errors has been a major focus for organized medicine since the publication of the Institute...

... training, which included training on root cause analysis and educational outreach, to enable them to deliver the PINCER Trial intervention. This was evaluated using self-report questionnaires at the end of each training session. The time taken to complete each session was recorded. Data from the evaluation...

... to prevent recurrence. Adverse event communication organisation root cause analysis teamwork Patient safety is still a major problem at many hospitals all over the world. Poor teamwork and communication between healthcare staff are correlated to patient safety and adverse events. ¹ Team...

..., stabilise or worsen. safety root cause analysis human error health system disasters safety culture health care quality The word disaster has its roots in Greek and Latin. In each language, the dis- refers to a pejorative, a moving away from or an absence of, while astrum...

... of this type. Improving patient safety will require that clinical laboratories and clinicians develop ways of working together to analyze and address these problems. Diagnostic error Laboratory error Quality improvement Communication Patient safety Root cause analysis Performance improvement Clinical...

...Laurentia Nodi; Ronald Balassanian; Daniel Sudilovsky; Stephen S. Raab Anatomic Pathology / ROOT CAUSE ANALYSIS IN CYTOLOGY Improving the Quality of Cytology Diagnosis Root Cause Analysis for Errors in Bronchial Washing and Brushing Specimens Laurentia Nodit, MD, Ronald Balassanian, MD...

... on an intensive care unit using root cause analysis L. Batty, K. Holland-Elliott and D. Rosenfeld Background Two doctors working on a busy intensive care unit sustained injuries whilst removing a chest drain from an HIV-positive patient...