The experience of the Root Cause Analysis (RCA) regarding the adverse event 'missing sample from the patient source'.
Creation of the Root Cause Analysis (RCA) represents a phase of clinical risk management and is the instrument chosen for reactive analysis of adverse events. It is important to consider RCA in the context of the entire clinical risk management process and to understand the interrelationships with t...
| Publicado en: | Professioni Infermieristiche Vol. 64; no. 3; pp. 131 - 137 |
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| Autores principales: | , , , , |
| Formato: | research tables/charts Journal Article |
| Publicado: |
Consociazione Nazionale Associazioni Infermiere/i (CNAI)
2011 Jul-Sep
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| Acceso en línea: | Ver este registro en EBSCOhost |
| fields | @attributes: recordID: 1 pdfLink: plink: https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=108203846&site=ehost-live header: @attributes: shortDbName: ccm uiTerm: 108203846 longDbName: CINAHL Complete uiTag: AN controlInfo: bkinfo: dissinfo: jinfo: jid: 00330205 Z17 jtl: Professioni Infermieristiche issn: 00330205 maglogo: N pubinfo: dt: 2011 Jul-Sep vid: 64 iid: 3 pid: 43398 pub: Consociazione Nazionale Associazioni Infermiere/i (CNAI) artinfo: ui: 108203846 108203846 2011374928 NLM22044543 108203846 ppf: 131 ppct: 6 formats: tig: atl: The experience of the Root Cause Analysis (RCA) regarding the adverse event 'missing sample from the patient source'. aug: au: Suprani, Riccarda Pellegrini, Rosalba Vitullo, Marialina Fabbri, Tulliio Cimmati, Marial Giulia affil: Funzione Aziendale Gestione del Rischio - AUSL Ravenna. sug: subj: Communication Health Care Errors Prevention and Control Occupational Exposure Prevention and Control Quality Improvement Methods Risk Management Root Cause Analysis Human Inpatients Italy Software ab: Creation of the Root Cause Analysis (RCA) represents a phase of clinical risk management and is the instrument chosen for reactive analysis of adverse events. It is important to consider RCA in the context of the entire clinical risk management process and to understand the interrelationships with the previous and subsequent phases, in order to identify the necessary input and the expected output of such activity. In this study the input consisted of the adverse event which occurred after a health worker had been exposed to a biological risk and the 'source patient sample' could not be found. The hospital and nursing authorities analyzed the event to understand its dynamics and causes. The results, or output, obtained indicate the steps necessary to go on to the next phase, namely treatment of the risk and the need for systemic measures: improvement of communication , revision of hospital procedures for managing blood samples and modification of the laboratory computer programs. pubtype: Academic Journal doctype: research tables/charts Journal Article ougenre: Article language: Italian refInfo: holdings: @attributes: islocal: N |
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