How to Use the Fishbone Tool for Root Cause Analysis
"By repeating "why" five times, the nature of the problem as well as its solution becomes clear," -S. Toyoda
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This guide was created as an adaptation from the Patient Safety & Quality Improvement Library guide created and managed by Debbie Thomas at Becker Medical Library.
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An international peer review publication providing research, opinions, debates and reviews for academics, clinicians and healthcare managers focused on the quality and safety of health care and the science of improvement |
Error reduction in health care: a systems approach to improving patient safety A good place to start is by getting an understanding not just of the extent of the medical injury, but also of the theories of why people make mistakes and how to prevent them. The next step is to learn what is available in terms of methods for understanding risk, analyzing mistakes, and designing care processes |
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Drug healthcare & patient safety An international, peer reviewed, open access journal exploring patient safety issues in the healthcare continuum from diagnostic and screening interventions through to treatment, drug therapy and surgery |
Washington Manual of Patient Safety and Quality Improvement, 2016 "We hope this manual provides a broad overview for the fundamentals of patient safety and quality improvement, as well as insight into how these principles apply to clinical settings. Each chapter of the manual starts with a clinical vignette and discussion questions meant to show how patient safety and quality improvement principles |
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The premier international journal covering the disciplines of pharmacovigilance, pharmacoepidemiology, benefit-risk assessment, risk management and medication error prevention. Drug Safety specializes in definitive reviews on the epidemiology, clinical features, prevention and management of adverse effects of individual drugs and drug classes |
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Joint commission journal on quality & patient safety a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care |
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The Journal of Patient Safety, an academic, peer-reviewed journal, is a new venue dedicated to both rigorous research and field application articles covering to all areas of patient safety and quality health care |
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Journal of patient safety & infection control The official journal of the Hospital Infection Society—India, is a peer-reviewed publication aimed at spreading awareness, encouraging and augmenting research and education in the field of healthcare associated infections and usage of antimicrobials in human infections and diseases in order to take patient safety and infection control to highest levels |
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This open access, online journal publishes articles on all issues related to safety and quality of patient care in surgery and surgical subspecialties |
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Therapeutic advances in drug safety delivers the highest quality peer-reviewed articles, reviews, and scholarly comment on pioneering efforts and innovative studies pertaining to the safe use of drugs in patients. The journal has a strong clinical and pharmacological focus and is aimed at clinicians and researchers in drug safety, providing a forum in print and online for publishing the highest quality articles in this area |
An error may allow a problem to pass through a hole in one layer, but in the next layer the holes are not lined up so the problem should be caught.