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JAMA, 2021 In the summer of 2020, a patient at a major Veteran Affairs medical center in the western United States experienced an unwitnessed fall in their telemetry patient ward. This incident resulted in the patient receiving a fracture in his/her C5 cervical spine area. This eventually led to his/her death the following day.
Paulsen M.
europepmc +6 more sources
Qualitative study on experience of healthcare staff who have undergone a hybrid root cause analysis training programme [PDF]
BMJ Open Quality, 2023 Background Root cause analysis (RCA) is a structured investigation methodology aimed at identifying systems factors to prevent recurrence of incidents. To enhance staff’s knowledge and skills, a hybrid RCA training course was conducted in February 2021 ...
Yick-Ting Kwok, Alastair P Mah
doaj +2 more sources
Can’t find the antidote: A root cause analysis [PDF]
Frontiers in Pharmacology, 2022 Background: In a series of cases that came to be recognized as a national methanol outbreak, an incident of delay in allocation and treatment with the antidote fomepizole is described with aim of sharing a learning experience.Method: A team of 16 members
Laila Carolina Abu Esba +7 more
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Root cause analysis – what do we know? [PDF]
MAB, 2021 Root cause analysis (RCA) provides audit firms, regulators, policy makers and practitioners the opportunity to learn from past adverse events and prevent them from reoccurring in the future, leading to better audit quality. Recently approved regulations (
Wendy Groot
doaj +3 more sources
Prevalence and Influencing Factors of Sedentary Behavior in Community Stroke Patients [PDF]
Zhongguo quanke yixue, 2022 BackgroundAs a kind of unhealthy lifestyle, sedentary behavior is closely related to poor prognosis of stroke patients. So it is of great significance to understand sedentary behavior prevalence in stroke patients, and to formulate intervention measures ...
FU Zhongrong, ZHANG Zhenxiang, LIN Beilei, MEI Yongxia, WANG Wenna
doaj +1 more source
MFM-based alarm root-cause analysis and ranking for nuclear power plants
Nuclear Engineering and Technology, 2023 Alarm flood due to abnormality propagation is the most difficult alarm overloading problem in nuclear power plants (NPPs). Root-cause analysis is suggested to help operators in understand emergency events and plant status.
Mengchu Song +4 more
doaj +1 more source
ASSOCIATION BETWEEN BLOOD 25-(OH)D3 LEVEL AND ACUTE INFECTIOUS DISEASES IN CHILDREN [PDF]
精准医学杂志, 2023 Objective To investigate the association between blood 25-hydroxyvitamin D3 [25-(OH)D3] level and acute infectious diseases in children. Methods A total of 114 children with acute infectious diseases who were admitted to our hospital from October 2021 to
ZHANG Zhe, PAN Hua, LYU Zhenmei, LI Li, YI Mingji, SONG Aiqin
doaj +1 more source
Medsurg nursing : official journal of the Academy of Medical-Surgical Nurses, 2013 This literature review will be to address the questions, ‘in what ways can a team, a group and an individual define problems’, as well as what are some of the ‘best practices for ensuring decision-making can avoid common pitfalls and how some solutions are engineered. For a team, group, or an individual to be properly equipped in not only acknowledging
Brenda M. Ewen, Gale Bucher
+8 more sources
African Journal of Laboratory Medicine, 2021 An international HIV pharmacology specialty laboratory (PSL) was established at the University of Zimbabwe to increase bioanalytical and investigator capacities.
Faithful Makita-Chingombe +11 more
doaj +1 more source
BMC Health Services Research, 2020 Background To evaluate the effectiveness of root cause analysis (RCA) recommendations and propose possible ways to enhance its quality in Hong Kong public hospitals.
Yick Ting A Kwok +2 more
doaj +1 more source