✂
What is an aggregate analysis?
An aggregate review is a type of root cause analysis. It is used when there are multiple occurences of the same type of event in the same three month reporting period (quarter).
✂ Which RCA for aggregate analysis?Topics for aggregate review are based on the Incident Reporting System,
preferring incidents that are high-volume and high-risk.
Current topics: patient falls, medication errors, missing patients,
and parasuicidal behavior (attempts and gestures).
- Provide a way to reveal trends not evident in individual case analysis
- Identify common root causes and implement comprehensive corrective action plans throughout the hospital
- Make wise use of an RCA team's time
To conduct an aggregate review:
- Continue the usual process to notify the Taiwan Joint Commission on Hospital Accreditation (TJCHA)
within 45 days[4] of confirming a severe adverse event
(
Never Events
). - Maintain a quarterly, chronological log of confirmed severe adverse events. Include a short summary of the event, the root causes and casual statement(s).
- When two or more of the same tpe of adverse event occur within the same quarter, identify common causes/circumstances that contributed to the multiple occurrences.
- Develop a corrective action plan that addresses all components of your overall prevention strategy.
This may include care coordination, equipment, documentation, clinical practice/knowledge, special clinical issues or organisational issues.
You will need to:
- Highlight the risk reduction plans for each component
- Identify who is responsible for making changes/corrections, a timeline for implementaion and your measures of success.
- Identify the members of your root cause analysis team and describe how you report this work to your leaders.
- Examples of aggregate reviews:
- Prepare an aggregate review report. Include the chronological log and your corrective action plan. Send your aggregate review report to TJCHA according to their published schedule.
References
- Neily J, Ogrinc G, Mills P, Williams R, Stalhandske E, Bagian J, Weeks WB. Using Aggregate Root Cause Analysis to Improve Patient Safety www.jointcommissionjournal.com 2003; 29(8): 434-439.
- Mills PD, Neily J, Luan D, Stalhandske E, Weeks WB. Using Aggregate Root Cause Analysis to Reduce Falls and Related Injuries www.sciencedirect.com 2005; 31(1): 21-31.
- Petzel RA. Department of Veteran Affairs, Washington, DC. VHA National Patient Safety Improvement Handbook (chapters 11~15) www.va.gov 2016; March.
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Medical Accident Prevention and Dispute Resolution Act Regulation Category: Administration > Ministry of Health and Welfare > Medical Affairs
Article 34- Medical institutions should analyze the root causes of major medical accidents, propose improvement plans, and notify the competent authorities.
- Regulations regarding major medical incidents that should be notified in the preceding paragraph, notification procedures, contents and other matters that must be followed shall be prescribed by the central competent authority.
- The notification of major medical accidents, root cause analysis and improvement plans in Paragraph 1 shall not be used as evidence or basis for judgment in the current medical dispute case, nor shall they be used as the basis for relevant administrative sanctions.