Decreasing Mortality for Patients Undergoing Hip Fracture Repair Surgery

Has Mortality After a Hip Fracture Increased?

“…With the significant changes in management of patients with hip fracture, more‐recent data are necessary to analyze factors of importance for survival. The only recent analysis showing improvements in mortality after hip fractures is a single center study in the United States 7 showing a decrease in mortality from 4.9% in 2000 to 0.8% in 2003 after implementation of a systematic preoperative assessment program. A large‐scale epidemiological study from Great Britain 8 covering 1968 to 1993 showed a decline in case fatality rates from 1968 to approximately 1980 but no decline from approximately 1980 to 1993.…”

Implementation and strength of root cause analysis recommendations following serious adverse events involving paediatric patients in the Queensland public health system between 2012 and 2014

“…7,8 There are, however, several small studies in the literature that demonstrate a decrease in a specific adverse event or a decrease in the incidence of a root cause that contributed to the event. [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25] Conversely, a recent large retrospective study of 302 RCAs in a New York hospital showed that multiple event types, such as retained foreign body, medication administration error and wrong-site surgery, occurred repeatedly in the study period despite repeated RCAs being performed. 26 In the absence of a controlled trial that tests the validity of the RCA framework in health care, there are several parameters that can be monitored to evaluate recommendations arising from RCA as a surrogate measure of their efficacy.…”

“…Despite the widespread use of RCA in health care and the significant costs associated with the process, there has been no formal evaluation of the ability of the RCA process to improve patient safety . There are, however, several small studies in the literature that demonstrate a decrease in a specific adverse event or a decrease in the incidence of a root cause that contributed to the event . Conversely, a recent large retrospective study of 302 RCAs in a New York hospital showed that multiple event types, such as retained foreign body, medication administration error and wrong‐site surgery, occurred repeatedly in the study period despite repeated RCAs being performed …”

Review of alternatives to root cause analysis: developing a robust system for incident report analysis

“…Why did it happen?’ and ‘How to prevent it from happening again?’27 They seek to analyse safety events through ‘a human factors engineering approach—entailing a search for system vulnerabilities rather than individual human errors and other less actionable root causes’ 28. RCA has been shown to improve safety and compliance with clinical processes 29–45. Studies have also identified problems with the methods by which RCAs are conducted and actions enacted 12 23 25 46–56.…”