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Root Cause Analysis for Hospital-Acquired Pressure Injury

Black, Joyce M.

Journal of Wound Ostomy & Continence Nursing: July/August 2019 - Volume 46 - Issue 4 - p 298–304
doi: 10.1097/WON.0000000000000546
Wound Care
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Root cause analysis (RCA) is a systematic process for identifying the causes of an adverse occurrence or combined with an approach for a response designed to prevent recurrences. This method may be used for continuous quality improvement in a facility or health system. Root cause analysis can aid nurses and hospital risk managers to determine how the system can improve to reduce the number and severity of pressure injuries. The process of RCA begins with being certain the wound is a pressure injury using differential diagnoses of similar appearing skin disease and injury, followed by an examination of the processes of care (human roots) for missed actions or inactions that are linked to development of a particular pressure injury. The final step of RCA is a critical examination of the system (including people and processes) to look for modifiable trends or patterns are identified that are used to prevent recurrences.

The CE test for this article is available online only at the journal website, jwocnonline.com, and the test can be taken online at NursingCenter.com/CE/JWOCN.

Joyce M. Black, PhD, RN, FAAN, College of Nursing, University of Nebraska Medical Center, Omaha.

Correspondence: Joyce M. Black, PhD, RN, FAAN, College of Nursing, University of Nebraska Medical Center, Omaha, NE 68198 (jblack@unmc.edu).

© 2019 by the Wound, Ostomy and Continence Nurses Society.