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M. Bar-on, R. Berkeley (2016)
Early Engagement of Residents Into the Root Cause Analysis Process.Journal of graduate medical education, 8 3
S. Quraishi, S. Kimatian, W. Murray, E. Sinz (2011)
High-fidelity simulation as an experiential model for teaching root cause analysis.Journal of graduate medical education, 3 4
Lakshmana Swamy, C. Worsham, Mark Bialas, Christa Wertz, David Thornton, Anthony Breu, Matthew Ronan (2018)
The 60-Minute Root Cause Analysis: A Workshop to Engage Interdisciplinary Clinicians in Quality ImprovementMedEdPORTAL : the Journal of Teaching and Learning Resources, 14
M. Murphy, J. Duff, J. Whitney, Benjamin Canales, M. Markham, J. Close (2017)
Implementation of a mock root cause analysis to provide simulated patient safety trainingBMJ Open Quality, 6
Quality improvement and patient safety education is an Accreditation Council for Graduate Medical Education (ACGME) common program requirement for hematology/oncology fellowships. Interprofessional clinical patient safety activities, such as root cause analyses (RCA), can be challenging to incorporate into busy schedules. We report on a multicentered experience utilizing a simulated RCA educational module in an attempt to provide fellows with the tools needed to participate in a live RCA and to increase awareness of the need to analyze patient safety events. The 2-h module included a didactic session explaining the basics of an RCA including common terminology, effective chart review, and personal interviews. The fellows assessed a patient safety event of a missed coagulopathy and created an event flow map and fishbone analysis. They then formed root cause/contributing factor statements and proposed a solution. Twenty-three fellows from two institutions completed the experience. There was a significant difference in fellow reported comfort with participating in a live RCA (p = 0.03), and in utilizing the tools of an RCA following the mock RCA experience (p = 0.005). About 70% of respondents felt that as a result of the mock RCA, they were more likely to report a near miss or adverse event and were more likely to be thorough in their documentation. Mock RCAs are a feasible method of incorporating ACGME-required patient safety activities into hematology/oncology fellow education and are effective in increasing their comfort and understanding of important quality improvement skills.
Journal of Cancer Education – Springer Journals
Published: Aug 1, 2022
Keywords: Graduate medical education; Root cause analysis; Simulation; Quality improvement
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