1. Cause-and-effect mapping of critical events.
- Author
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Graves K, Simmons D, and Galley MD
- Subjects
- Anticoagulants adverse effects, Causality, Drug Labeling, Heparin adverse effects, Humans, Indiana epidemiology, Joint Commission on Accreditation of Healthcare Organizations, Los Angeles epidemiology, Medication Errors mortality, Medication Errors statistics & numerical data, National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division, Problem Solving, Thinking, United States epidemiology, Data Interpretation, Statistical, Medication Errors prevention & control, Outcome and Process Assessment, Health Care methods, Safety Management methods, Systems Analysis, Total Quality Management methods
- Abstract
Health care errors are routinely reported in the scientific and public press and have become a major concern for most Americans. In learning to identify and analyze errors health care can develop some of the skills of a learning organization, including the concept of systems thinking. Modern experts in improving quality have been working in other high-risk industries since the 1920s making structured organizational changes through various frameworks for quality methods including continuous quality improvement and total quality management. When using these tools, it is important to understand systems thinking and the concept of processes within organization. Within these frameworks of improvement, several tools can be used in the analysis of errors. This article introduces a robust tool with a broad analytical view consistent with systems thinking, called CauseMapping (ThinkReliability, Houston, TX, USA), which can be used to systematically analyze the process and the problem at the same time., (Copyright 2010 Elsevier Inc. All rights reserved.)
- Published
- 2010
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