Application of Root Cause Analysis to Improve the Safety of Patients: A Case Study of Adverse Event

2.50
Hdl Handle:
http://hdl.handle.net/10755/335347
Category:
Full-text
Type:
Presentation
Title:
Application of Root Cause Analysis to Improve the Safety of Patients: A Case Study of Adverse Event
Author(s):
Lin, Fang-Ru
Lead Author STTI Affiliation:
Non-member
Author Details:
Fang-Ru Lin, RN, linlyn0101@gmail.com
Abstract:
Session presented on Sunday, July 27, 2014: Purpose: Head trauma and limb fracture are common consequences of falls in children. The aim of this study was to describe the adverse event with falls children in hospitalized. We used root cause analysis to survey the adverse event on practices relevant to improving patient safety. Methods: The setting of this study was about a 24-bed pediatric oncology ward in northern regional teaching hospital in Taiwan from January, 2010 to November, 2013. The first applied instrument was based on literatures review. We would retrospectively chart review and 'reporting system of medical incidents' describing in detail the adverse event and activities to leading up this. Then, we constructed the event diagram to show the steps in the process where fail maybe. We were made based on these root cause to avoid adverse events. Results: The total errors events 23 adverse events (Systemic errors: 2; personal errors: 21).We found those questions: 1. Children are largely dependent on the age of the child is main risk factor. Mean age of the children was 5.8 years old. More than half of all fall-related childhood injuries occur among children age 3 years (about 56.6%). 2. Lack of main caregiver on the alert (lack of main caregiver watched closely) is a common cause of falls (about 86%). Conclusion: Falls are a leading cause of children morbidity, mortality and high risk of interruption or delaying chemotherapy in cancer patients. Based on our results, we suggested to provide appropriate the tools to educate children and main caregivers of the potential risk of falls and was to develop individualized management plans of care to reduce risk for high risk children.
Keywords:
Falls; Falls in hospitalized; children
Repository Posting Date:
17-Nov-2014
Date of Publication:
17-Nov-2014 ; 17-Nov-2014
Other Identifiers:
INRC14PST266
Conference Date:
2014
Conference Name:
25th International Nursing Research Congress
Conference Host:
Sigma Theta Tau International, the Honor Society of Nursing
Conference Location:
Hong Kong
Description:
International Nursing Research Congress, 2014 Theme: Engaging Colleagues: Improving Global Health Outcomes. Held at the Hong Kong Convention and Exhibition Centre, Wanchai, Hong Kong

Full metadata record

DC FieldValue Language
dc.language.isoen_USen_GB
dc.language.isoenen
dc.type.categoryFull-texten
dc.typePresentationen
dc.titleApplication of Root Cause Analysis to Improve the Safety of Patients: A Case Study of Adverse Eventen
dc.contributor.authorLin, Fang-Ruen
dc.contributor.departmentNon-memberen
dc.author.detailsFang-Ru Lin, RN, linlyn0101@gmail.comen
dc.identifier.urihttp://hdl.handle.net/10755/335347-
dc.description.abstractSession presented on Sunday, July 27, 2014: Purpose: Head trauma and limb fracture are common consequences of falls in children. The aim of this study was to describe the adverse event with falls children in hospitalized. We used root cause analysis to survey the adverse event on practices relevant to improving patient safety. Methods: The setting of this study was about a 24-bed pediatric oncology ward in northern regional teaching hospital in Taiwan from January, 2010 to November, 2013. The first applied instrument was based on literatures review. We would retrospectively chart review and 'reporting system of medical incidents' describing in detail the adverse event and activities to leading up this. Then, we constructed the event diagram to show the steps in the process where fail maybe. We were made based on these root cause to avoid adverse events. Results: The total errors events 23 adverse events (Systemic errors: 2; personal errors: 21).We found those questions: 1. Children are largely dependent on the age of the child is main risk factor. Mean age of the children was 5.8 years old. More than half of all fall-related childhood injuries occur among children age 3 years (about 56.6%). 2. Lack of main caregiver on the alert (lack of main caregiver watched closely) is a common cause of falls (about 86%). Conclusion: Falls are a leading cause of children morbidity, mortality and high risk of interruption or delaying chemotherapy in cancer patients. Based on our results, we suggested to provide appropriate the tools to educate children and main caregivers of the potential risk of falls and was to develop individualized management plans of care to reduce risk for high risk children.en
dc.subjectFallsen
dc.subjectFalls in hospitalizeden
dc.subjectchildrenen
dc.date.available2014-11-17T13:50:17Z-
dc.date.issued2014-11-17-
dc.date.issued2014-11-17en
dc.date.accessioned2014-11-17T13:50:17Z-
dc.conference.date2014en
dc.conference.name25th International Nursing Research Congressen
dc.conference.hostSigma Theta Tau International, the Honor Society of Nursingen
dc.conference.locationHong Kongen
dc.descriptionInternational Nursing Research Congress, 2014 Theme: Engaging Colleagues: Improving Global Health Outcomes. Held at the Hong Kong Convention and Exhibition Centre, Wanchai, Hong Kongen
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