Analysis of the root causes of an undesirable incident in a hospital in Mashhad, 2013

Zohourian, P. and Amini, A. S. and Davooodi, R. and Shojaeian, M. (2016) Analysis of the root causes of an undesirable incident in a hospital in Mashhad, 2013. Bangladesh Journal of Medical Science, 15 (4). pp. 637-644.

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Medical errors are equivalent to costly failures. In other words, it is the behavior and/or decision which do not comply with healthcare standards. Thus, this study aimed to analyze the root causes of an undesirable incident which lead to the death of a 24-year-old intern who had been in contact with a patient with Crimean-Congo Hemorrhagic Fever (CCHF). She was referred to the infectious section with symptoms of a cold and fever which was accompanied by hemorrhage and respiratory distress. Unfortunately, she passed away four days later in one of the hospitals in Mashhad in 2013. The current research is a descriptive study which was conducted through the qualitative method in 5 steps. The steps were as follows: defining the incident, data collection, outlining the identification of the issues, data analysis and identification of the root causes and working out solutions and implementation concerning the same incident in May 2013. In the process, such tools as diagramming cause and effect and storming thoughts were applied. A number of reasons were identified to have given rise to the incident. The lack of quarantine areas in the emergency section of the hospital, the negligence of the senior resident of the infectious diseases ward as to consider the need to isolate the patients, the negligence of the responsible intern as to take into account the similar cases which had been recorded in the morning report of the hospital on the same day, inadequate surgical consultations given by the senior resident according to the hospital policy and last but not least, inefficient education in universal precautions of the disease for the staff and students. The analysis of such fatal errors in the field of patient safety is of paramount importance. Thus, these techniques should be used in healthcare centers in order to evaluate critical situations systematically. © 2016, Ibn Sina Trust. All rights reserved.

Item Type: Article
Additional Information: Cited By :1 Export Date: 16 February 2020 Correspondence Address: Amini, A.S.; Mashhad University of Medical SciencesIran; email:
Uncontrolled Keywords: Analysis of the root causes Hospital Patient Undesirable incident fresh frozen plasma ribavirin adult antibiotic therapy Article bleeding bradycardia case report clinical education common cold Crimean Congo hemorrhagic fever data analysis descriptive research dialysis catheter disease severity echography female fever headache heart arrhythmia hospital policy human incidence intubation Iran medical documentation medical error medical record review negligence oliguria patient isolation patient safety qualitative analysis quarantine respiratory distress resuscitation root cause analysis stomach distension thrombocyte transfusion universal precaution young adult
Subjects: WX Hospital and other health Facilities
Divisions: Mashhad University of Medical Sciences
Depositing User: mr lib4 lib4
Date Deposited: 04 Mar 2020 04:49
Last Modified: 04 Mar 2020 04:49

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