PMID- 28528624
OWN - NLM
STAT- MEDLINE
DCOM- 20190729
LR  - 20190729
IS  - 1553-7250 (Print)
IS  - 1553-7250 (Linking)
VI  - 43
IP  - 6
DP  - 2017 Jun
TI  - Root Cause Analysis of Adverse Events in an Outpatient Anticoagulation Management 
      Consortium.
PG  - 299-307
LID - S1553-7250(17)30121-6 [pii]
LID - 10.1016/j.jcjq.2017.03.007 [doi]
AB  - BACKGROUND: A number of factors can lead to adverse events (AEs) in patients 
      taking warfarin. Performing a root cause analysis (RCA) of serious AEs is one 
      systematic way of determining the causes of these events. METHODS: 
      Multidisciplinary teams were formed at Michigan Anticoagulation Quality 
      Improvement Initiative (MAQI(2)) sites with organized anticoagulation management 
      services (AMS). Medical records from patients who suffered serious AEs (major 
      bleed, embolic stroke, venous thromboembolism) were reviewed, and AMS staff were 
      interviewed to determine the root cause using the "5 Whys" technique. More than 
      600 patients had an AE and underwent screening by trained RNs. Of these, 79 
      required full review by a multidisciplinary panel. All potential contributing 
      factors (comorbidities, concurrent medications, current protocols) were assessed 
      to determine the main factor that caused the AE. RESULTS: Full RCA was completed 
      in 79 cases. The main contributing factor was identified in 69/79 (87%) cases. 
      Most identified AEs, 55/69 (80%), were due to patient-specific factors such as 
      comorbidities. Patient-to-provider and provider-to-provider communication 
      accounted for 16/69 (23%) of events and was the second most common cause. Other 
      causes included protocol non-adherence and technology/equipment issues. After 
      each detailed review, the multidisciplinary panel recommended system changes that 
      addressed the primary cause. CONCLUSION: The majority of severe AEs for patients 
      taking warfarin were related to nonmodifiable patient-related issues. The 
      remaining AEs were primarily due to patient-to-provider and provider-to-provider 
      communication issues. Methods for improving communication need to be addressed, 
      and methods for more effective patient education should be investigated.
CI  - Copyright (c) 2017 The Joint Commission. Published by Elsevier Inc. All rights 
      reserved.
FAU - Graves, Christopher M
AU  - Graves CM
FAU - Haymart, Brian
AU  - Haymart B
FAU - Kline-Rogers, Eva
AU  - Kline-Rogers E
FAU - Barnes, Geoffrey D
AU  - Barnes GD
FAU - Perry, Linda K
AU  - Perry LK
FAU - Pluhatsch, Denise
AU  - Pluhatsch D
FAU - Gearhart, Nannette
AU  - Gearhart N
FAU - Gikas, Helen
AU  - Gikas H
FAU - Ryan, Noelle
AU  - Ryan N
FAU - Kurtz, Brian
AU  - Kurtz B
LA  - eng
PT  - Journal Article
PT  - Research Support, Non-U.S. Gov't
DEP - 20170419
PL  - Netherlands
TA  - Jt Comm J Qual Patient Saf
JT  - Joint Commission journal on quality and patient safety
JID - 101238023
RN  - 0 (Anticoagulants)
RN  - 5Q7ZVV76EI (Warfarin)
MH  - Anticoagulants/*adverse effects
MH  - Clinical Protocols
MH  - Communication
MH  - Comorbidity
MH  - Hemorrhage/chemically induced/mortality
MH  - Humans
MH  - *Outpatients
MH  - Patient Safety
MH  - Professional-Patient Relations
MH  - Quality Improvement/*organization & administration
MH  - *Root Cause Analysis
MH  - Stroke/prevention & control
MH  - Venous Thromboembolism/prevention & control
MH  - Warfarin/*adverse effects
EDAT- 2017/05/23 06:00
MHDA- 2019/07/30 06:00
CRDT- 2017/05/23 06:00
PHST- 2017/05/23 06:00 [entrez]
PHST- 2017/05/23 06:00 [pubmed]
PHST- 2019/07/30 06:00 [medline]
AID - S1553-7250(17)30121-6 [pii]
AID - 10.1016/j.jcjq.2017.03.007 [doi]
PST - ppublish
SO  - Jt Comm J Qual Patient Saf. 2017 Jun;43(6):299-307. doi: 
      10.1016/j.jcjq.2017.03.007. Epub 2017 Apr 19.