Application Root Cause Analysis Technique in Investigating the Causes of a Fatal Sentinel Event: Case Report

Chaharsoughi, Narges Toghian; Emadi, Fatemeh

doi:10.29252/ijn.30.107.53

Cited by 2 publications

(2 citation statements)

References 13 publications

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“…The aim is to analyze the root causes of sentinel events that caused death in one hospital in Isfahan in 2015. This study concludes that the benefits of Root Cause analysis can be used to prevent similar errors from happening, eliminate organizational defects, improve processes within an organization, and improve patient safety 16 .…”

Section: Figure 5 Distribution Of Dimension Of Incident Evaluation and Best Practicesmentioning

confidence: 84%

Safety Culture Assessment: a Tool for Improving Patient Safety in Hospital

Agustina

2018

JMMR

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The patient safety culture at the 'X' Hospital Palembang is still not good enough as can be seen from the number of reported patient safety incidents from KPRS team. Meanwhile, this C-type hospital is obligated to implement patient safety culture in improving health service quality. This research uses quantitative method with cross-sectional approach. The research samples are taken using Slovin's formula from medic and paramedic, medical support, and management and sampling with proportional stratified random sampling. Measurement of patient safety culture uses MaPSaF (Mancheste Patient Safety Framework) questionnaire which has been published by NPSA (National Patient Safety Agency) in 2006 and has been tested for its validity and reliability by previous research. The questionnaire consists of 10 dimensions with 24 aspects of the question. The implementation of patient safety culture at the 'X' Hospital Palembang has been in accordance with MaPSaF assessment of 70% at proactive level, 20% at generative level, and also 10% at bureaucratic level. Overall, the patient safety culture is dominant at the proactive level, yet improvement is still needed to the generative level by raising awareness, good cooperation, and responsibility for the importance of patient safety culture.Budaya keselamatan pasien di Rumah Sakit 'X' Palembang masih belum cukup baik, hal ini dapat dilihat dari banyaknya pelaporan insiden keselamatan pasien dari tim KPRS. Padahal, rumah sakit tipe C ini wajib menerapkan budaya keselamatan pasien dalam meningkatkan kualitas pelayanan kesehatan. Penelitian ini menggunakan metode kuantitatif dengan pendekatan cross-sectional. Sampel penelitian menggunakan rumus Slovin yang diambil dari tenaga medis dan paramedis, dukungan medis, dan manajemen dan pengambilan sampel dengan proportional stratified random sampling. Pengukuran budaya keselamatan pasien MaPSaF (Mancheste Patient Safety Framework) menggunakan National Patient Safety Agency (NPSA) pada tahun 2006 dan telah diuji validitas dan reliabilitas dengan penelitian sebelumnya. Kuesioner terdiri dari 10 dimensi dengan 24 aspek pertanyaan. Implementasi Rumah Sakit 'X' Palembang sesuai dengan penilaian MaPSaF sebesar 70% pada tingkat proaktif, 20% pada tingkat generatif, dan juga 10% pada tingkat birokrasi. Secara keseluruhan, budaya keselamatan pasien dominan pada tingkat proaktif, tetapi masih perlu perbaikan ke tingkat generatif dengan meningkatkan kesadaran, kerjasama yang baik, dan tanggung jawab untuk pentingnya budaya keselamatan pasien.

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Section: Figure 5 Distribution Of Dimension Of Incident Evaluation and Best Practicesmentioning

confidence: 84%

Safety Culture Assessment: a Tool for Improving Patient Safety in Hospital

Agustina

2018

JMMR

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“…Identifying the cause of the incidents is important to prevent the errors through enables the creation of effective measures to reduce the likelihood of similar negative events occurring in the future [ 31 , 32 ]. Likewise, root cause analysis is a process of investigating the root cause or sources of mistakes and vulnerabilities in a system to reduce the rate of adverse events [ 33 ].…”

Section: Discussionmentioning

confidence: 99%

Clinical incident reporting behaviors and associated factors among health professionals in Dessie comprehensive specialized hospital, Amhara Region, Ethiopia: a mixed method study

Yalew

Yitayew

2021

BMC Health Serv Res

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Background Understanding the type and causes of errors are necessary for the prevention of occurrence or reoccurrence. Therefore addressing the behavior of health professionals on reporting clinical incidents is crucial to create spontaneous knowledge from mistakes and enhance patient safety. Method A mixed type institution-based cross-sectional study design was conducted from March 1 - 30, 2020 in Dessie comprehensive specialized hospital among 319 and 18 participants for the quantitative and qualitative study, respectively. The professions and participants with their assigned proportions were selected using a simple random sampling technique. For quantitative and qualitative data, semi structured questionnaires and interviewer-guided questions were used to collect data, respectively. Finally, qualitative findings were used to supplement the quantitative result. Result The finding showed that the proportion of clinical incident reporting behavior among health professionals was 12.4%. Having training (AOR=3.6, 95% CI, 1.15-11.45), incident reporting help to minimize errors (AOR=2.8, 95% CI, 1.29-6.02), fear of legal penalty (AOR= 0.3, 95% CI, 0.13-0.82), and lack of feedback (AOR=0.3, 95% CI, 0.11-0.90) were identified as significant factors for clinical incident reporting behavior of the health professionals. Conclusions This study showed that the clinical incident reporting behavior of the health professionals was very low. Therefore health professionals should get training on clinical incident reporting and the hospital should have an incident reporting system and guideline.

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Application Root Cause Analysis Technique in Investigating the Causes of a Fatal Sentinel Event: Case Report

Cited by 2 publications

References 13 publications

Safety Culture Assessment: a Tool for Improving Patient Safety in Hospital

Safety Culture Assessment: a Tool for Improving Patient Safety in Hospital

Clinical incident reporting behaviors and associated factors among health professionals in Dessie comprehensive specialized hospital, Amhara Region, Ethiopia: a mixed method study

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