Zastrow RL. Root cause analysis in infusion nursing: applying quality improvement tools for adverse events. J Infus Nurs. 2015;38(3):225-231.
The application of root cause analysis (RCA) to health care began in the Veteran’s Administration system and spread to Joint Commission-accredited organizations when it became a requirement for accreditation. The success of this valuable quality improvement tool relies on understanding the principles of patient safety, assembling a team, and producing and completing action items aimed at correcting root causes of adverse events. This article describes optimal RCA techniques based on published literature and expert opinion and then provides a sample RCA for a fictitious but common adverse event: catheter-associated bloodstream infection.
published on IV Team 19 Apr 2015 www.ivteam.com