Titel: Åtta steg identifierar brister i systemet [summary] (serie: Tema patientsäkerhet) 2007 nr 4 sid 232-4

Läs/ladda hem artikeln: Översikt Artikeln i pdf-format Sid 232 Sid 233 Sid 234 Om Läkartidningens fulltext på Internet

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Summary:

This article describes root cause analysis of serious adverse events in healthcare as performed in Östergötland, Sweden. Our work is based on a manual recently published in Sweden in which well-established methods have been adapted to the Swedish healthcare system (1). The head of the department initiates an analysis where the adverse event has occurred, and a team of three or four healthcare professionals is formed. After collection of relevant data subsequent analysis provides a detailed description of the event itself and identifies the root causes. Measures that should be taken to prevent recurrence of the adverse event as well as recommendations regarding follow-up are proposed. Finally the head of the department decides which actions are to be carried out.