Investigating the Causes of Adverse Events

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Presentation transcript:

Investigating the Causes of Adverse Events Juan A. Sanchez, MD, Kevin W. Lobdell, MD, Susan D. Moffatt-Bruce, MD, PhD, James I. Fann, MD The Annals of Thoracic Surgery Volume 103, Issue 6, Pages 1693-1699 (June 2017) DOI: 10.1016/j.athoracsur.2017.04.001 Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 The cause-and-effect (or Ishikawa) diagram is one of several basic tools that can be used in a root cause analysis to show causal relationships and contributory factors leading to an adverse event [10, 15, 21]. The Annals of Thoracic Surgery 2017 103, 1693-1699DOI: (10.1016/j.athoracsur.2017.04.001) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions