What are the experiences of team members involved in root cause analysis? A qualitative study.

BACKGROUND: Conducting root cause analysis (RCA) is complex and challenging. The aim of this study was to better understand the experiences of RCA team members and how they value their involvement in the RCA to inform future recruitment, conduct and implementation of RCA findings into clinical practice. METHODS: The study was set in a health network in Adelaide, South Australia. A qualitative exploratory descriptive approach was undertaken to provide an in-depth understanding of team member's experience in participating in an RCA. Eight of 27 RCA team members who conducted RCAs in the preceding 3-year period were included in one of three semi-structured focus groups. Thematic analysis was used to synthesise the transcribed data into themes. RESULTS: We derived four major themes: Experiences and perceptions of the RCA team, Limitations of RCA recommendations, Facilitators and barriers to conducting an RCA, and Supporting colleagues involved in the adverse event. Participants' mixed experience of RCAs ranged from enjoyment and the perception of worth and value to concerns about workload and lack of impact. Legislative privilege protecting RCAs from disclosure was both a facilitator and a barrier. Concern and a desire to better support their colleagues was widely reported. CONCLUSIONS: Clinicians perceived value in reviewing significant adverse events. Improvements can be made in sharing learnings to make effective improvements in health care. We have proposed a process to better support interviewees and strengthen post interview follow up.

Mortality at Music Festivals: An Update for 2016-2017 - Academic and Grey Literature for Case Finding.

In 2016, the authors published a paper on music festival fatalities between the years 1999 and 2014 (n=722). In this Special Report, they provide an update on fatalities reported at music festivals globally for the period 2016-2017 (n=201). Using a search strategy designed to capture grey literature and media reports of music festival fatalities, reports of the overall frequency and cause-of-death breakdown for publicly reported, festival-related deaths are recorded. This update shows an increase in the frequency of festival-related fatality reports during the new period, together with an increase in the number of deaths attributable to terror (n=60) and overdose/poisoning (n=41). Drawing conclusions about the cause of this increase is challenging given the growth in Internet use, online media reports, and number of music festivals occurring annually when compared with the previous reporting period. The authors re-emphasize the need for a uniform reporting standard and reliable epidemiological data for fatalities related to music festivals, mass gatherings, and special events. TurrisSA, JonesT, LundA. Mortality at music festivals: an update for 2016-2017 - academic and grey literature for case finding. Prehosp Disaster Med. 2018;33(5):553-557.

Neutropenic sepsis.

What was the nature of the CPD activity, practice-related feedback and/or event and/or experience in your practice? The article discussed the causes, signs and symptoms of neutropenic sepsis in adult patients after cancer treatment. It also explored the prevention and management of this condition.

Fecal ostomies: practical management for the home health clinician.

Ostomy creation is a common surgical procedure that affects more than 120,000 individuals annually in the United States. Ostomy patients require lifelong specialized support and care directed toward improving their health status, promoting self-care, and facilitating long-term adjustment. Home health clinicians are responsible for the assessment and management of the complex needs of the ostomy patient and must be able to identify and appropriately intervene when complications arise. This article will provide the home health clinician with an overview of fecal ostomy care and management, and review the role of the clinician in the management of the patient.