Root Cause Analysis Reports Help Identify Common Factors In Delayed Diagnosis And Treatment Of Outpatients

• DOI: 10.1377/hlthaff.2013.0130
• Publication Date: 2013-08-05T21:52:19Z
• Authors: Traber Davis Giar...; Beth J. King; Aartee P. Ignaczak; Douglas E. Paull; Laura Hoeksema; Peter D. Mills; Julia Neily; Robin R. Hemphill; Hardeep Singh
• Keywords: Root Cause Analysis; Veterans Affairs

Delays in diagnosis and treatment are widely considered to be threats outpatient safety. However, few studies have identified described what factors contribute delays that might result patient harm the setting. We analyzed 111 root cause analysis reports investigated such were submitted Veterans Affairs National Center for Patient Safety period 2005–12. The most common contributing noted included coordination problems resulting from inadequate follow-up planning, delayed scheduling unspecified reasons, tracking of test results, absence a system track patients need short-term follow-up. Other team-level decision-making miscommunication urgency between providers providers’ lack awareness or knowledge about patient’s situation; communication failures among providers, patients, other health care team members. Our findings suggest support goals Affordable Care Act Quality Strategy, even relatively sophisticated electronic record systems will require enhancements. At same time, policy initiatives should programs implement, perhaps reward use of, more rigorous interprofessional teamwork principles improve coordination.