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Improvements to Root Cause Analysis of Patient Safety Events


Patient safety and adverse events are a major problem across the healthcare continuum, generating substantial costs and negative health implications. Although there has been significant focus towards their improvement over the course of the last 30 years, progress has been slow and limited.


The objective of this project was to understand inter-rater reliability of selected safety analysis methods and study the relative advantages and disadvantages of these methods compared to Root Cause Analysis RCA.


Training materials were developed and used to prep undergraduate and graduate students for going to the VA National Center for Patient Safety (NCPS) in Ann Arbor.  A VA site visit was conducted and a team of researchers were then based at the VA in Ann Arbor, MI to assess local patient safety and adverse event data. It was identified that FRAM, a safety assessment method, could be an alternative to RCA since FRAM evaluates safety events from a nonlinear systems approach.

Project Team

  • Lindsay Baldo

  • Nicholas Fasano

  • Ali Hobbs

  • Karen Chen

  • Awatef Ergai

  • Saytan Chari

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