Tip: Determine the root cause of a ’never event’
APCs Weekly Monitor, February 26, 2010
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Never events, such as wrong-site surgeries, are actually rare events, says Alsie Fitzgerald, RN, CASC, board chair of the ASC Association. If a never event occurs, conduct a root-cause analysis, she says. The following questions can help determine what went wrong:
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Was it human error?
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Was it a process?
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Was it a piece of equipment?
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Was it the environment?
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Why did this happen and what can we do to prevent it from recurring?
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Did we hurry and not follow the process?
This tip is adapted from “Prevent and react to outpatient never events” in the February issue of Briefings on APCs.
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