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Chapter 21 - Creating a Learning Culture

Debriefing and Root-cause Analysis

Published online by Cambridge University Press:  15 March 2018

Thomas Ivester
Affiliation:
University of North Carolina, Chapel Hill
Patrice M. Weiss
Affiliation:
Virginia Polytechnic Institute and State University
Paul A. Gluck
Affiliation:
University of Miami
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Publisher: Cambridge University Press
Print publication year: 2018

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References

Say, L, Souza, JP, Pattinson, RC, WHO Working Group on Maternal Mortality and Morbidity Classifications. Maternal near miss – towards a standard tool for monitoring quality of maternal health care. Best Pract Res Clin Obstet Gynaecol. 2009;23(3):287296.CrossRefGoogle ScholarPubMed
Manser, T. Managing the aftermath of critical incidents: meeting the needs of health-care providers and patients. Best Pract Res Clin Anaesthesiol. 2011;25(2): 169179.Google Scholar
Salas, E, Klein, C, King, H, et al. Debriefing medical teams: 12 evidence-based best practices and tips. Joint Comm J Qual Patient Saf. 2008;34(9):518527.Google ScholarPubMed
Scott, SD, Hirschinger, LE, Cox, KR, McCoig, M, Brandt, J, Hall, L. The natural history of recovery for the health care provider “second victim” after adverse patient events. Qual Saf Health Care. 2009;18(5):325330.Google Scholar
Zigmong, JJ, Kappus, LJ, Sudikoff, SN. The 3D model of debriefing: defusing, discovering and deepening. Semin Perinatol. 2011;35:5258.Google Scholar
Hughes, RG. Tools and strategies for quality improvement and patient safety. In: Hughes, RG, ed. Patient Safety and Quality: An Evidence-based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008. Chapter 44. Available from: www.ncbi.nlm.nih.gov/books/NBK2682/Google Scholar
Ahmed, M, Sevdails, N, Paige, J, Paragi-Gururaja, R, Nestel, D, Arora, S. Identifying best practice guidelines for debriefing in surgery: a tri-continental study. Am J Surg. 2012;203;523529.CrossRefGoogle Scholar
Preventing Infant Death and Injury During Delivery. Sentinel Event Alert; Issue 30. Oakbrook Terrace, IL: The Joint Commission; 2004. Available at: www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_30.htmGoogle Scholar
Riley, W, Hansen, H, Gürses, AP, Davis, S, Miller, K, Priester, R. The nature, characteristics and patterns of perinatal critical events teams. In: Henriksen, K, Battles, JB, Keyes, MA, Grady, ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches, Volume 3: Performance and Tools. Rockville, MD: Agency for Healthcare Research and Quality; 2008.Google Scholar
Rooney, JJ, Vanden Heuval, LN. Root cause analysis for beginners. Quality Progress. 2004;4553.Google Scholar
AHRQ Patient Safety Network Root Cause Analysis. www.psnet.ahrq.gov/primer.aspx?primerID=10Google Scholar
Hor, Su-yin, Iedema, R, Williams, K, White, L, Kennedy, P, Day, AS. Multiple accountabilities in incident reporting and management. Qual Health Res. 2010;20(8):10911100.Google Scholar
Gluck, PA. Patient safety in obstetrics and gynecology: improving outcomes, reducing risks medical error theory. Obstet Gynecol Clin. 2008;35(1):1117.CrossRefGoogle Scholar
Web M&M. Morbidity and Mortality Rounds on the Web. Patient safety primers-systems approach. AHRQ. http://webMM.ahrq.gov/primer.aspx?primerID=21 (accessed June 4, 2013).Google Scholar

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