Abstract
Pathologists and pathology laboratory personnel provide care for patients within increasingly complex healthcare delivery systems. Systems and infrastructure are imperfect, as are humans, and thus all types of diagnostic error are inevitable. Understanding root causes and systemic vulnerabilities is at the core of root cause analysis (RCA), as is improving patient safety. This chapter describes root cause analysis as a standardized tool for managing patient safety events within pathology and laboratory medicine. Specific techniques are covered including how to assemble an RCA team, using fishbone diagrams, cause maps, and process maps, as well as disseminating the results of a successful RCA. Benefits of successful RCA include improved safety culture, risk reduction for patient safety events, and workforce engagement.
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Chen, Y., Heher, Y.K. (2019). Root Cause Analysis in Surgical Pathology. In: Nakhleh, R., Volmar, K. (eds) Error Reduction and Prevention in Surgical Pathology. Springer, Cham. https://doi.org/10.1007/978-3-030-18464-3_16
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DOI: https://doi.org/10.1007/978-3-030-18464-3_16
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