Health Information Management

Tip: Determine the root cause of a ’never event’

APCs Insider, 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:
 
  • Was it human error?
  • Was it a process?
  • Was it a piece of equipment?
  • Was it the environment?
  • Why did this happen and what can we do to prevent it from recurring?
  • 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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