Application of root cause analysis to improve the safety of patients: A case study of adverse event
View File(s)
Visitor Statistics
Visits vs Downloads
Visitors - World Map
Top Visiting Countries
Country | Visits |
---|
Top Visiting Cities
City | Visits |
---|
Visits (last 6 months)
Downloads (last 6 months)
Popular Works for Lin, Fang-Ru by View
Title | Page Views |
---|
Popular Works for Lin, Fang-Ru by Download
Title | Downloads |
---|
View Citations
Citations
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.
International Nursing Research Congress, 2014 Theme: Engaging Colleagues: Improving Global Health Outcomes. Held at the Hong Kong Convention and Exhibition Centre, Wanchai, Hong Kong
Items submitted to a conference/event were evaluated/peer-reviewed at the time of abstract submission to the event. No other peer-review was provided prior to submission to the Henderson Repository.
Type | Poster |
Acquisition | Proxy-submission |
Review Type | Abstract Review Only: Reviewed by Event Host |
Format | Text-based Document |
Evidence Level | N/A |
Research Approach | N/A |
Keywords | Falls; Falls in Hospitalized Patient; Children |
Name | 25th International Nursing Research Congress |
Host | Sigma Theta Tau International |
Location | Hong Kong |
Date | 2014 |
All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record.
All permission requests should be directed accordingly and not to the Sigma Repository.
All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.
Related items
Showing items related by title, author, creator and subjects.
-
Effects of geriatric training program on RNs' geriatric care competencies in hospitals
Yueh, Fang-Ru; Chang, Ying Ju; Hu, Fang-WenThe health problems of hospitalized elderly patients are complicated.However, there is lack of geriatric training program for nurses in hospitals. The study is to develop a geriatric training program and to evaluate the ... -
Reducing falls in long-term care with root cause analysis method
Antanovich, Michelle L. (2016-09-26)Session presented on Monday, September 19, 2016: Falls among the elderly are a public health problem that has economic and quality of life burdens not only to the individual patient, but also to society. The Joint Commission ... -
Safety culture: Medication adverse event tracking at a pediatric oncology hospital in Guatemala
Zelaya, Liliana; Dray, Emily (2017-07-03)Purpose: The ECHO Project: Educacion de Cuidados Intensivos en un Hospital de Oncologia is a multidisciplinary educational collaborative between the Medical-Surgical Intensive Care Unit at Boston Children’s Hospital ... -
The influence of helping relationships from significant others on healthy lifestyle among patients with chronic kidney disease
Chao, Shu-Mei; Yueh, Fang-Ru; Yen, Miaofen (2014-11-17)Session presented on Sunday, July 27, 2014: Purpose: The aim of research is to study and explore helping relationships impact on establishing healthy lifestyle among patients with chronic kidney disease (CKD). The positive ... -
The effect of Root Cause Analysis on safe medication administration
Miller, Kristi Sanborn (2018-03-15)Though Root Cause Analysis has been required for sentinel events for many years, there is little evidence for efficacy. This study explores the impact of RCA on nursing knowledge and attitudes about safe medication administration.