J Patient Saf. 2022 Apr 30. doi: 10.1097/PTS.0000000000001016. Online ahead of print.
ABSTRACT
OBJECTIVES: Although patient safety continues to be a priority in the U.S. healthcare system, delays in diagnosis, treatment, or surgery still led to adverse events for patients. The purpose of this study was to review root cause analysis (RCA) reports in the Veterans Health Administration to identify the root causes and contributing factors of delays in diagnosis, treatment, or surgery in an effort to prevent avoidable delays in future care.
METHODS: The RCA reports from Veterans Health Administration hospitals from October 2016 through September 2019 were reviewed and the root causes and contributory factors were identified. These elements were coded by consensus and analyzed using descriptive statistics.
RESULTS: During the 3-year study period, 206 RCAs were identified and 163 were analyzed that were specific to delays in diagnosis, treatment, and surgery. The reports identified 24 delays in diagnosis, 117 delays in treatment, and 22 delays in surgery. Delays occurred most often in outpatient settings.
CONCLUSIONS: Results supported the need for standardization of care processes and procedures, improved communication between and within department personnel, and improved policies and procedures that will be followed as intended. By reviewing adverse events, root causes, and contributing factors identified by local RCA teams, strategies can be developed to reduce delays in diagnosis and treatment of patients and lead to safer care.
PMID:35532991 | DOI:10.1097/PTS.0000000000001016
