Application of root cause analysis on malpractice claim files related to diagnostic failures

Quality & Safety in Health Care
I van NoordM C de Bruijne

Abstract

Large numbers of claim files present a potentially valuable source of information to get insight on possibilities for prevention of claims. Therefore, the feasibility of root cause analyses on incidents leading to liability claims at The Netherlands' largest medical liability insurer was assessed. Feasibility was defined by validity, reliability and applicability. Claim files from diagnostic errors in emergency departments of Dutch hospitals were selected. All closed and settled claim files from the year 2001 and 2002 were used. Fifty incidents occurring at 31 emergency departments were found in 47 files. 114 root causes were found, on average 2.3 per incident. 78% of the incidents were related to missed fractures, luxations or tendon lesions. Zero technical, 29% organisational, 66.7% human-related and 4.4% patient-related factor errors were found. Inter-rater agreement for classification of root causes was good (κ = 0.78). Preventive measures following from Prevention and Recovery Information System for Monitoring and Analysis (PRISMA) classification-action matrix were improving completion of available sources of information, improving structures of communication and training staff to prevent failures due to the wrong implemen...Continue Reading

Citations

Dec 18, 2013·International Journal for Quality in Health Care : Journal of the International Society for Quality in Health Care·Inge Verbeek-Van NoordMartine C De Bruijne
Feb 14, 2014·International Journal for Quality in Health Care : Journal of the International Society for Quality in Health Care·Douglas P SlakeyJames R Korndorffer
Oct 15, 2011·Radiographics : a Review Publication of the Radiological Society of North America, Inc·Jonathan B KruskalPhillip M Boiselle
May 16, 2018·The International Journal of Risk & Safety in Medicine·Hesty Utami RamadaniatiLynne Maree Emmerton
May 29, 2019·Simulation in Healthcare : Journal of the Society for Simulation in Healthcare·Anna-Theresa LobosMélissa Langevin

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