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Journal Article
Published articles related to CRPPutting the “Action” in RCA2: An Analysis of Intervention Strength After Adverse Events
Published articles related to CRP
Decription
Zerillo, Tardiff, Flood, Sokol-Hesner, and Weiss retrospectively coded 148 corrective actions from 67 safety events brought to a tertiary care academic medical center’s multidisciplinary hospital-level safety event review meeting from 2020 to 2021. They coded by category and strength, using the US Department of Veterans Affairs/Institute for Healthcare Improvement Action Hierarchy Tool. They found an inverse relationship between intervention strength and completion; the strongest interventions had the lowest rate of completion. Also, the majority of corrective actions were categorized as weak.
This article highlights the importance of developing systems for tracking the completion of corrective actions. Without tracking data on completion, organizations cannot know how well they are mitigating the risks to safety that their analyses have identified. By integrating action strength and completion status into corrective action follow-up, healthcare organizations may more effectively identify and address those barriers to completing the strongest interventions that ultimately achieve high reliability.
Citation
Jessica A. Zerillo, Sarah A. Tardiff, Dorothy Flood, Lauge Sokol-Hessner, Anthony Weiss, Putting the “Action” in RCA2: An Analysis of Intervention Strength After Adverse Events, The Joint Commission Journal on Quality and Patient Safety, 2024, ISSN 1553-7250, https://doi.org/10.1016/j.jcjq.2024.03.012.