How to complete root cause analysis (RCA) for CLABSI

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“This article describes optimal RCA techniques based on published literature and expert opinion and then provides a sample RCA for a fictitious but common adverse event: catheter-associated bloodstream infection” Zastrow et al (2015).

Reference:

Zastrow, R.L. (2015) Root Cause Analysis in Infusion Nursing: Applying Quality Improvement Tools for Adverse Events. Journal of Infusion Nursing. 38(3), p.225–231.

Abstract:

The application of root cause analysis (RCA) to health care began in the Veteran’s Administration system and spread to Joint Commission-accredited organizations when it became a requirement for accreditation. The success of this valuable quality improvement tool relies on understanding the principles of patient safety, assembling a team, and producing and completing action items aimed at correcting root causes of adverse events. This article describes optimal RCA techniques based on published literature and expert opinion and then provides a sample RCA for a fictitious but common adverse event: catheter-associated bloodstream infection.

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