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.
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.
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.
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.
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.
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.
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.
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.