Root Cause Analysis of Oncology Adverse Events in the Veterans Health Administration

Aboumrad, Maya; Fuld, Alexander; Soncrant, Christina; Neily, Julia; Paull, Douglas E.; Watts, Bradley V.

doi:10.1200/jop.18.00159

Cited by 9 publications

(8 citation statements)

References 65 publications

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“…” In addition, root cause analysis should be used in the disclosure of PSIs. Root cause analysis concentrates on systematic and organizational factors that led to the PSIs and are useful for identifying what happened, why it happened, and what can be done next to prevent it from happening again 34 . However, considering that the disclosure of PSIs negatively impacts clinical staff, healthcare professionals may conceal that they have been involved in a mistake.…”

Section: Discussionmentioning

confidence: 99%

Experience and support of Chinese healthcare professionals as second victims of patient safety incidents: A cross‐sectional study

Yan

Jian-cheng

Chen

et al. 2021

Perspect Psychiatric Care

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Purpose To describe the experience and support of Chinese healthcare professionals as second victims of PSIs. Design and Methods A cross‐sectional study with anonymous online self‐report questionnaires was adopted. A total of 1357 Chinese healthcare professionals participated in this study. The Chinese version of the Second Victim Experience and Support Tool (C‐SVEST) was used to evaluate the experience of second victims and the quality of support resources. Descriptive and inferential statistics were employed to analyze the data. Findings This study showed that 350 participants (25.8%) had been involved in PSIs during their careers. The majority of respondents who had experienced PSIs agreed they suffered more from psychological distress, followed by professional self‐efficacy distress, and physical distress. Besides, they regarded colleague support and management support as the most desirable support. Statistically significant differences were reported in some items. First, compared with medical staff without professional titles, staff with professional titles suffered more from psychological distress but gained more support from colleagues. Practice implications The second victim phenomenon deserves further attention. The programs focusing on training qualified colleagues to provide emotional support should be developed, implemented, and evaluated. Moreover, it is necessary to build a better patient safety culture with nonpunitive responses and encourage the disclosure and reporting of PSIs.

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Section: Discussionmentioning

confidence: 99%

Experience and support of Chinese healthcare professionals as second victims of patient safety incidents: A cross‐sectional study

Yan

Jian-cheng

Chen

et al. 2021

Perspect Psychiatric Care

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“…1 Patient harm is often a consequence of medical errors, which can involve system-based mistakes, including missed or delayed diagnoses, miscommunication between care teams, and misadministration of medication. [2][3][4][5] The resulting impact on the patient ranges from no harm to death. [2][3][4][5] While current initiatives and collaborative practices strive to make patient care safer, adverse events still occur.…”

Section: Introductionmentioning

confidence: 99%

“…[2][3][4][5] The resulting impact on the patient ranges from no harm to death. [2][3][4][5] While current initiatives and collaborative practices strive to make patient care safer, adverse events still occur. In the United States, medical errors have emerged as the third leading cause of death, accounting for more than 250 000 deaths each year.…”

Section: Introductionmentioning

confidence: 99%

“…Common efforts include standardization of care processes, or recognizing and improving specific aspects of care. [2][3][4][5] Moreover, hospitals dedicated to patient safety may use a more foundational approach, such as establishing and promoting a patient safety culture. 7,8 This may result in system-wide changes that improve a broader range of care aspects.…”

Section: Introductionmentioning

confidence: 99%

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Teaching Root Cause Analysis Using Simulation: Curriculum and Outcomes

Aboumrad

Neily

Watts

2019

Journal of Medical Education and Curricular Development

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Background:Clinicians are key drivers for improving health care quality and safety. However, some may lack experience in quality improvement and patient safety (QI/PS) methodologies, including root cause analysis (RCA).Objective:The Department of Veterans Affairs (VA) sought to develop a simulation approach to teach clinicians from the VA’s Chief Resident in Quality and Safety program about RCA. We report the use of experiential learning to teach RCA, and clinicians’ preparedness to conduct and teach RCA post-training. We provide curriculum details and materials to be adapted for widespread use.Methods:The course was designed to meet the learning objectives through simulation. We developed course materials, including presentations, a role-playing case, and an elaborate RCA case. Learning objectives included (1) basic structure of RCA, (2) process flow diagramming, (3) collecting information for RCA, (4) cause and effect diagramming, and (5) identifying actions and outcomes. We administered a voluntary, web-based survey in November 2016 to participants (N = 114) post-training to assess their competency with RCA.Results:A total of 93 individuals completed the survey of the 114 invited to participate, culminating an 82% response rate. Nearly all respondents (99%, N = 92) reported feeling at least moderately to extremely prepared to conduct and teach RCA post-training. Most respondents reported feeling very to extremely prepared to conduct and teach RCA (77%, N = 72).Conclusions:Experiential learning involving simulations may be effective to improve clinicians’ competency in QI/PS practices, including RCA. Further research is warranted to understand how the training affects clinicians’ capacity to participate in real RCA teams post-training, as well as applicability to other disciplines and interdisciplinary teams.

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“…Strategies to improve coordination processes for VA cancer patients are timely and warranted as inadequate care coordination and interdisciplinary communication have recently emerged as root causes of many oncology-related adverse events in the VA. 47 Future studies should explore strategies to help oncology and primary care to work together as a team around a specific patient' cancer pain management needs. Strategies to establish cross-disciplinary role agreement, 39 providing clear guidance around when and how coprescribing can occur, and minimizing provider resistance to therapeutically appropriate prescribing may be helpful.…”

Section: Discussionmentioning

confidence: 99%

Cross Disciplinary Role Agreement is Needed When Coordinating Long‐Term Opioid Prescribing for Cancer: a Qualitative Study

et al. 2021

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BACKGROUND: Cancer pain is highly prevalent and often managed in primary care or by oncology providers in combination with primary care providers. OBJECTIVES: To understand interdisciplinary provider experiences coordinating opioid pain management for patients with chronic cancer-related pain in a large integrated healthcare system. DESIGN: Qualitative research. PARTICIPANTS: We conducted 20 semi-structured interviews with interdisciplinary providers in two large academically affiliated VA Medical Centers and their associated community-based outpatient clinics. Participants included primary care providers (PCPs) and oncology-based personnel (OBPs). APPROACH: We deductively identified 94 examples of care coordination for cancer pain in the 20 interviews. We secondarily used an inductive open coding approach and identified themes through constant comparison coming to research team consensus. RESULTS: Theme 1: PCPs and OBPs generally believed one provider should handle all opioid prescribing for a specific patient, but did not always agree on who that prescriber should be in the context of cancer pain. Theme 2: There are special circumstances where having multiple prescribers is appropriate (e.g., a pain crisis). Theme 3: A collaborative process to opioid cancer pain management would include real-time communication and negotiation between PCPs and oncology around who will handle opioid prescribing. Theme 4: Providers identified multiple barriers in coordinating cancer pain management across disciplines. CONCLUSIONS:Our findings highlight how real-time negotiation about roles in opioid pain management is needed between interdisciplinary clinicians. Lack of crossdisciplinary role agreement may result in delays in clinically appropriate cancer pain management.

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Root Cause Analysis of Oncology Adverse Events in the Veterans Health Administration

Cited by 9 publications

References 65 publications

Experience and support of Chinese healthcare professionals as second victims of patient safety incidents: A cross‐sectional study

Experience and support of Chinese healthcare professionals as second victims of patient safety incidents: A cross‐sectional study

Teaching Root Cause Analysis Using Simulation: Curriculum and Outcomes

Cross Disciplinary Role Agreement is Needed When Coordinating Long‐Term Opioid Prescribing for Cancer: a Qualitative Study

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