Root Cause Analysis: Can It Improve Outcome after Transjugular Intrahepatic Portosystemic Shunt Creation?

Abstract

Root cause analysis (RCA) was developed to identify “the basic and causal factors that underlie variation in performance” ( 1 National Patient Safety Foundation. RCA2–Improving root cause analyses and actions to prevent harm. Available from: https://c.ymcdn.com/sites/npsf.site-ym.com/resource/resmgr/PDF/RCA2_first-online-pub_061615.pdf. Accessed July 2015. Google Scholar ). It was introduced into the medical community in the mid-1990s to systematically investigate the causes of serious adverse events ( 2 Wu A.W. Lipshutz A.K.M. Pronovost P.J. Effectiveness and efficiency of root cause analysis in medicine. JAMA. 2008; 299: 685-687 Crossref PubMed Scopus (244) Google Scholar ). RCA is designed to answer three basic questions ( 3 U.S. Department of Veterans Affairs. VA National Center for Patient Safety: root cause analysis (RCA). Available from: http://www.patientsafety.va.gov/professionals/onthejob/rca.asp. Accessed July 2015. Google Scholar ): what happened, why did it happen, and what can be done to prevent its recurrence? It is always retrospective by addressing a problem in the past, but it may have a prospective impact by providing a solution that prevents the error and improves outcome. Root Cause Analysis of Rebleeding Events following Transjugular Intrahepatic Portosystemic Shunt Creation for Variceal HemorrhageJournal of Vascular and Interventional RadiologyVol. 26Issue 10PreviewTo identify fundamental causes underlying recurrent variceal hemorrhage (VH) after transjugular intrahepatic portosystemic shunt (TIPS) to ascertain opportunities for improvement of TIPS-based management of VH and prevention of rebleeding. Full-Text PDF