The Joint Commission journal on quality improvement
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Jt Comm J Qual Improv · Oct 2000
Comparative StudySystematic root cause analysis of adverse drug events in a tertiary referral hospital.
Adverse drug events (ADEs) occur frequently, and serious ADEs are associated with mortality or prolonged morbidity. As many ADEs are preventable, identification and modification of systems and processes that permit ADEs has the potential to reduce the rate of ADEs. ⋯ Systematic application of root cause analysis followed by implementation of process changes that target the underlying cause(s) of each event can be successfully implemented in a large hospital.