scholarly journals Root Cause Analysis to Identify Medication and Non-Medication Strategies to Prevent Infection-Related Hospitalizations from Australian Residential Aged Care Services

2020 ◽  
Vol 17 (9) ◽  
pp. 3282
Author(s):  
Janet K. Sluggett ◽  
Samanta Lalic ◽  
Sarah M. Hosking ◽  
Brett Ritchie ◽  
Jennifer McLoughlin ◽  
...  
Keyword(s):  
Root Cause Analysis ◽  
Aged Care ◽  
Models Of Care ◽  
Medical Services ◽  
Residential Aged Care ◽  
Care Needs ◽  
Cause Analysis ◽  
Root Cause ◽  
Care Services ◽  
Timely Access

Infections are leading causes of hospitalizations from residential aged care services (RACS), which provide supported accommodation for people with care needs that can no longer be met at home. Preventing infections and early and effective management are important to avoid unnecessary hospital transfers, particularly in the Australian setting where new quality standards require RACS to minimize infection-related risks. The objective of this study was to examine root causes of infection-related hospitalizations from RACS and identify strategies to limit infections and avoid unnecessary hospitalizations. An aggregate root cause analysis (RCA) was undertaken using a structured local framework. A clinical nurse auditor and clinical pharmacist undertook a comprehensive review of 49 consecutive infection-related hospitalizations from 6 RACS. Data were collected from nursing progress notes, medical records, medication charts, hospital summaries, and incident reports using a purpose-built collection tool. The research team then utilized a structured classification system to guide the identification of root causes of hospital transfers. A multidisciplinary clinical panel assessed the root causes and formulated strategies to limit infections and hospitalizations. Overall, 59.2% of hospitalizations were for respiratory, 28.6% for urinary, and 10.2% for skin infections. Potential root causes of infections included medications that may increase infection risk and resident vaccination status. Potential contributors to hospital transfers included possible suboptimal selection of empirical antimicrobial therapy, inability of RACS staff to establish on-site intravenous access for antimicrobial administration, and the need to access subsidized medical services not provided in the RACS (e.g., radiology and pathology). Strategies identified by the panel included medication review, targeted bundles of care, additional antimicrobial stewardship initiatives, earlier identification of infection, and models of care that facilitate timely access to medical services. The RCA and clinical panel findings provide a roadmap to assist targeting services to prevent infection and limit unnecessary hospital transfers from RACS.

scholarly journals Root cause analysis of fall-related hospitalisations among residents of aged care services

2019 ◽  
Vol 32 (10) ◽  
pp. 1947-1957 ◽  
Author(s):  
Janet K. Sluggett ◽  
Samanta Lalic ◽  
Sarah M. Hosking ◽  
Jenni Ilomӓki ◽  
Terry Shortt ◽  
...  
Keyword(s):  
Root Cause Analysis ◽  
Aged Care ◽  
Cause Analysis ◽  
Root Cause ◽  
Care Services

scholarly journals To err is human: medication patient safety in aged care, a case study

2018 ◽  
Vol 19 (2) ◽  
pp. 126-134
Author(s):  
Julia Gilbert ◽  
Jeong-ah Kim
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Medication Management ◽  
Care Facility ◽  
Root Cause Analysis ◽  
Aged Care ◽  
Cause Analysis ◽  
Content Type ◽  
Root Cause

Purpose The purpose of this paper is to explore an identified medication error using a root cause analysis and a clinical case study. Design/methodology/approach In this paper the authors explore a medication error through the completion of a root cause analysis and case study in an aged care facility. Findings Research indicates that medication errors are highly prevalent in aged care and 40 per cent of nursing home patients are regularly receiving at least one potentially inappropriate medicine (Hamilton, 2009; Raban et al., 2014; Shehab et al., 2016). Insufficient patient information, delays in continuing medications, poor communication, the absence of an up-to-date medication chart and missed or significantly delayed doses are all linked to medication errors (Dwyer et al., 2014). Strategies to improve medication management across hospitalisation to medication administration include utilisation of a computerised medication prescription and management system, pharmacist review, direct communication of discharge medication documentation to community pharmacists and staff education and support (Dolanski et al., 2013). Originality/value Discussion of the factors impacting on medication errors within aged care facilities may explain why they are prevalent and serve as a basis for strategies to improve medication management and facilitate further research on this topic.

Preventing 30-day readmissions for patients with cancer: A root-cause analysis.

2021 ◽  
Vol 39 (28_suppl) ◽  
pp. 226-226
Author(s):  
Manan P Shah ◽  
Irena Tan ◽  
Sarah K. Garrigues ◽  
Jennifer Hansen ◽  
Douglas W. Blayney ◽  
...  
Keyword(s):  
Ambulatory Care ◽  
Academic Medical Center ◽  
Root Cause Analysis ◽  
Urgent Care ◽  
Cancer Center ◽  
Cause Analysis ◽  
Patients With Cancer ◽  
Root Cause ◽  
Timely Access ◽  
Key Drivers

226 Background: The high rate of unplanned 30-day readmissions for patients with cancer is a significant driver of costs and a marker of poor quality. In this study, we analyzed 30-day readmissions at our cancer center to determine causality and propose key drivers to prevent them. Methods: Patients with known cancer who were readmitted to our academic medical center within 30 days of a previous hospitalization were identified in our electronic health record by a third-party algorithm. Among patients with hematologic malignancies, only those undergoing bone marrow transplant care were included. Surveys querying causality and preventability of the readmissions were sent to the patients’ attending oncologists. Electronic chart documentation of readmissions were reviewed by two investigators to assess causality and preventability of each readmission. Results were discussed in focus groups to determine key drivers to prevent 30-day readmissions. Results: 437 readmissions were identified between 9/1/19 and 8/31/20, and 182 readmissions with corresponding surveys completed by their oncologists were identified (Table). Based on survey responses, 30 (16%) of the 182 readmissions were preventable, whereas based on our review, 56 (31%) were preventable. The top three causes of the 56 preventable readmissions were: underutilized ambulatory care (43%), premature discharge (23%), and goals of care discordance (16%). For underutilized ambulatory care, the primary treatments provided during those readmissions were: procedures such as thoracentesis and paracentesis (42%), medication administration for pain or nausea (33%), and infusions or transfusions (25%). Notably, most of these patients either did not attempt to seek outpatient care (42%) or were not able to secure an ambulatory appointment (29%) prior to their readmission. Through focus group discussions, we found that the key drivers to reduce preventable 30-day readmissions at our institution are (1) timely access to outpatient pleural effusion and ascites management, (2) timely access to ambulatory management of cancer-related symptoms (e.g., pain, nausea, weakness), (3) increased systems-wide awareness and utility of avenues of urgent care, and (4) increased palliative care efforts in patients with readmissions. Conclusions: Systematic review of 30-day readmissions revealed a greater than anticipated portion of preventable readmissions. Root-cause analysis yielded key drivers to reduce 30-day readmissions at our cancer center.[Table: see text]

Root Cause analysis of SG tube ODSCC indications within the tube sheets of NPP biblis unit A

2011 ◽  
pp. 78-86
Author(s):  
R. Kilian ◽  
J. Beck ◽  
H. Lang ◽  
V. Schneider ◽  
T. Schönherr ◽  
...  
Keyword(s):  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause

Rule Construction and its Execution for Root Cause Analysis

2012 ◽  
Vol 132 (10) ◽  
pp. 1689-1697
Author(s):  
Yutaka Kudo ◽  
Tomohiro Morimura ◽  
Kiminori Sugauchi ◽  
Tetsuya Masuishi ◽  
Norihisa Komoda
Keyword(s):  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause

Root Cause Analysis Techniques Using Picosecond Time Resolved LADA

2014 ◽  
Author(s):  
Dan Bodoh ◽  
Kent Erington ◽  
Kris Dickson ◽  
George Lange ◽  
Carey Wu ◽  
...  
Keyword(s):  
Integrated Circuits ◽  
Picosecond Laser ◽  
Root Cause Analysis ◽  
Fault Isolation ◽  
Time Resolved ◽  
Cause Analysis ◽  
Root Cause ◽  
Design And Manufacturing ◽  
Multiple Interactions ◽  
Established Technique

Abstract Laser-assisted device alteration (LADA) is an established technique used to identify critical speed paths in integrated circuits. LADA can reveal the physical location of a speed path, but not the timing of the speed path. This paper describes the root cause analysis benefits of 1064nm time resolved LADA (TR-LADA) with a picosecond laser. It shows several examples of how picosecond TR-LADA has complemented the existing fault isolation toolset and has allowed for quicker resolution of design and manufacturing issues. The paper explains how TR-LADA increases the LADA localization resolution by eliminating the well interaction, provides the timing of the event detected by LADA, indicates the propagation direction of the critical signals detected by LADA, allows the analyst to infer the logic values of the critical signals, and separates multiple interactions occurring at the same site for better understanding of the critical signals.

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