sampling studies are limited in their power to accurately reflect all of nurses’ work (Carayon et al., 2003) because the method assumes that the tasks involved are observable, unambiguous, mutually exclusive, and exhaustive—not always the case with much of nursing work.

Root-cause analysis Root-cause analysis has long been used in engineering to examine organizational or system problems. It is a retrospective, qualitative process aimed at uncovering the underlying cause(s) of an error by looking past the “sharp end” of an error (see Chapter 1) to the enabling latent conditions that contributed to or enabled the occurrence of the error. Root-cause analysis involves a cycle of questions: What happened? Why did it happen? What were the most proximate factors causing it to happen? Why did those factors occur? and What systems and processes underlie those proximate factors? Answers to these questions help identify barriers and causes of problems so similar problems can be prevented in the future.

JCAHO requires that health care organizations perform root-cause analysis in response to all sentinel events. JCAHO also requires that HCOs, based on the results of this root-cause analysis, develop and implement an action plan consisting of improvements designed to reduce risk and monitor the effectiveness of those improvements (JCAHO, 2003). Wald and Shojania (2001) note that root-cause analysis is a labor-intensive process, and that there is not yet evidence that by itself it can improve patient safety. However, they also observe that the technique provides HCOs with a formal structure for learning from past mistakes.

Anticipatory failure analysis While root-cause analysis is performed in response to an adverse event that has already occurred, anticipatory failure analysis is used to identify and eliminate known and/or potential failures, problems, and errors from a system, design, process, and/or service before they occur. Failure modes and effects analysis (FMEA) is one technique used to conduct this type of analysis. Its goal is to prevent errors from occurring by attempting to identify all of the ways a device or process can fail, estimate the probability and consequence of each failure, and then take action to prevent the potential failures from occurring. Failure modes and effects analysis is typically conducted by multidisciplinary teams in an HCO on many different patient care processes, including device design. It is used to assess both existing and new products and processes (Carayon et al., 2003).

“LEAN” operations Root-cause analysis and anticipatory failure analysis are typically used to help nurses perform desirable, “value-added” nursing activities, such as medication administration, documentation, and patient monitoring, more efficiently or safely. LEAN operation techniques address not the enhancement of desirable, value-added activities, but the elimination of undesirable, often invisible activities—the waste inherent in

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