LibGuides: DHA-7005: Week 6 Resources

Week 6 Resources

Agency for Healthcare Research and Quality
This link through AHRQ provides a complete list of what is termed never events- sentinel events that should never happen.
How to Use the Fishbone Tool for Root Cause Analysis
Center for Medicare and Medicaid Services. (n.d.). How to use the fishbone tool for root cause analysis.
An illustrative and brief narrative on the use of the fishbone tool, frequently used to determine the reason for quality deficits.
Root Cause Analysis: Learning from Adverse Safety Events
Brook, O. R., Kruskal, J. B., Eisenberg, R. L., & Larson, D. B. (2015). Root cause analysis: Learning from adverse safety events. RadioGraphics, 35(6), 1655-1657.
How to use root cause analysis to investigate adverse outcomes.
Sentinel Event Policy and Procedures
Provides information on how to proceed with an investigation of sentinel events.
Top Ten Reasons for Process Improvement Project Failures
Antony, J., & Gupta, S. (2019). Top ten reasons for process improvement project failures. International Journal of Lean Six Sigma, 10(1), 367-374.
This article attributes the main reason for quality deficits to management failure.

The Healthcare Quality Book by David B. Nash; Maulik Joshi; Elizabeth R. Ransom; Scott B. Ransom
ISBN: 9781640550537
Publication Date: 2019-04-01
Barr, S. M., & Micciche. (2019). The role of the National Committee for Quality Assurance. In D. B. Nash, M. Joshi, E. R. Ransom, & S. B. Ransom (Eds.), The healthcare quality book: Vision, strategy, and tools (4th ed.). Health Administration Press.
Read Chapter 15 (pp. 389-394). These pages in Chapter 15 provide a good introduction to the NCQA and its role in defining and measuring quality through HEDIS measures.

A Comparison of Medication Administration Errors from Original Medication Packaging and Multi-Compartment Compliance Aids in Care Homes: A Prospective Observational Study
Gilmartin-Thomas, J. F.-M., Smith, F., Wolfe, R., & Jani, Y. (2017). A comparison of medication administration errors from original medication packaging and multi-compartment compliance aids in care homes: A prospective observational study. International Journal of Nursing Studies, 72, 15–23.
Failure Modes and Effects Analysis
FMEA Tool and Model from IHI.
A proactive method, similar to root cause analysis for evaluating process to determine challenges preventing success.
Predictors of Gaps In Patient Safety and Quality in U.S. Hospitals
Unruh, L., & Hofler, R. (2016). Predictors of gaps in patient safety and quality in U.S. hospitals. Health Services Research, 51(6), 2258–2281.
Describes the indicators of problems with patient safety.

Quality of Care Patient Safety
Medicaid. (2018). Quality of care patient safety.
A discussion of safeguarding patients as one of the most important quality of care indicators.

Quality Indicators Toolkit
Agency for Healthcare Research and Quality. (n.d.)
Go to the website and type “Quality Indicators Toolkit” into the search bar.
AHRQ Quality Indicators Toolkit - All PDF Files
A compendium of tools for evaluating quality including a PowerPoint for a BOD.
Use the search bar to learn more about measuring and responding to deaths from medical errors.
RCA2: Improving Root Cause Analyses and Actions to Prevent Harm
National Patient Safety Foundation. (2015). RCA2: Improving root cause analyses and actions to prevent harm.
This discussion takes a different approach with its focus on root cause analysis for sentinel events.
Understanding Patient Safety and Quality Outcome Data
Easter, K., & Tamburri, L. M. (2018). Understanding patient safety and quality outcome data. Critical Care Nurse, 38(6), 58–66.
Offers approach to interpreting patient safety data.