Developing, Implementing, Evaluating Electronic Apparent Cause Analysis Across a Health Care System.
| Autor: | Oster CA, Woods E, Mumma J, Murphy DJ |
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| Jazyk: | angličtina |
| Zdroj: | Joint Commission journal on quality and patient safety [Jt Comm J Qual Patient Saf] 2024 Oct; Vol. 50 (10), pp. 724-736. Date of Electronic Publication: 2024 Jun 01. |
| DOI: | 10.1016/j.jcjq.2024.05.009 |
| Abstrakt: | An interdisciplinary team developed, implemented, and evaluated a standardized structure and process for an electronic apparent cause analysis (eACA) tool that includes principles of high reliability, human factors engineering, and Just Culture. Steps include assembling a team, describing what happened, determining why the event happened, determining how defects might be fixed, and deciding which defects will be fixed. The eACA is an intuitive tool for identifying defects, apparent causes of those defects, and the strongest corrective actions. Moreover, the eACA facilitates system learning by aggregating apparent causes and corrective action trends to prioritize and implement system change(s). (Copyright © 2024 The Joint Commission. Published by Elsevier Inc. All rights reserved.) |
| Databáze: | MEDLINE |
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