A Cross-Sectional Study on the Relationship Between Utilization of Root Cause Analysis and Patient Safety at 139 Department of Veterans Affairs Medical Centers

摘要

In 1999 the Institute of Medicine reported that each year preventable medical errors lead to the deaths of at least 44,000 hospitalized Americans,and there is little indication of appreciable progress in recent years.The Joint Commission makes the distinction between "an adverse outcome that is primarily related to the natural course of the patients illness or underlying condition" and a "reviewable sentinel event," which is "a death or major permanent loss of function that is associated with the treatment (including 'recognized complications') or lack of treatment of that condition, or otherwise not clearly and primarily related to the natural course of the patient's illness or underlying condition."