Cost-effectiveness and budget impact analysis of Daratumumab, Lenalidomide and dexamethasone for relapsed-refractory multiple myeloma.

BACKGROUND: The prominent efficacy in terms of increasing progression-free survival (PFS) of Daratumumab, Lenalidomide and dexamethasone (DRd) triplet therapy versus Carfilzomib, Lenalidomide and dexamethasone (KRd) was proven previously in relapsed-refractory multiple myeloma (RRMM). However, the cost effectiveness of DRd versus KRd is unknown. METHODS: We developed a Markov model by using an Iranian payer perspective and a 10-year time horizon to estimate the healthcare cost, Quality-adjusted life years (QALYs) and life years gain (LYG) for DRd and KRd triplet therapies. Clinical data were obtained from meta-analyses and randomized clinical trials (RCTs). One-way and probabilistic sensitivity analysis were performed to assess model uncertainty. Budget impact analysis of 5 years of treatment under the DRd triplet therapy was also analysed. RESULTS: DRd was estimated to be more effective compared to KRd, providing 0.28 QALY gain over the modelled horizon. DRd-treated patients incurred $264 in total additional costs. The incremental cost utility ratio (ICUR) and cost effectiveness ratio (ICER) were $956/QALY and $472/LYG respectively. The budget impact analysis indicates that adding Daratumumab to Lenalidomide and dexamethasone regimen, in the first 5 years, will increase the healthcare system's expenses by $6.170.582. CONCLUSION: DRd triplet therapy compared to KRd is a cost-effective regimen for RRMM under Iran willingness-to-pay threshold.

Cost-effectiveness and budget impact analysis of enzalutamide in comparison to abiraterone in treatment of metastatic prostate cancer resistant to castration in Iran.

INTRODUCTION: In recent years, enzalutamide and abiraterone have been widely used as treatments for metastatic castration-resistant prostate cancer (mCRPC). However, the cost-effectiveness of these drugs in Iran is unknown. This study evaluated the cost-effectiveness of enzalutamide for the treatment of metastatic prostate cancer resistant to castration in Iran. METHODS: A 3-state Markov model was developed to evaluate the cost-effectiveness of enzalutamide and abiraterone from a social perspective over 10 years. The clinical inputs were obtained from the meta-analysis studies. The direct medical costs were obtained from the tariffs of the healthcare system, while the direct non-medical and indirect costs were collected from the patients. The data of utilities were derived from the literature. In addition, sensitivity analyses were conducted to assess the uncertainties. RESULTS: Compared with Abiraterone, enzalutamide was associated with a high incremental cost-effectiveness ratio (ICER) of $6,260 per QALY gained. According to the one-way sensitivity analysis, ICER was most heavily influenced by the prices of enzalutamide and Abiraterone, non-medical costs, and indirect costs. Regardless of the variation, enzalutamide remained cost-effective. The budget impact analysis of enzalutamide in the health system during 5 years was estimated at $6,362,127. CONCLUSIONS: At current prices, adding enzalutamide to pharmaceutical lists represents the cost-effective use of the healthcare resources in Iran for the treatment of metastatic castration-resistant prostate cancer.

Estimating the number of required nurses in different types of hospitals: An application of the workload indicators of staffing needs (WISNS) method.

BACKGROUND: Health system performance depends on the availability, accessibility, acceptability, and quality of health workforces. Policymakers seek whether the number of nurses is optimally matched based on patients' needs. This study aimed to assess the workforce stock, workload activities, activity standards, and workload pressure to determine the number of required nurses in different types of hospitals in Iran. METHODS: This study applied the workload indicators of staffing needs (WISNs) method and was conducted in 22 surgical and internal medicine wards at five hospitals in the southwest of Iran during six months. A time-motion study, and several group discussions, interviews were used to extract the required data. Descriptive statistics were used for data analysis. RESULTS: All selected hospitals faced nursing shortages. The highest shortage (-47) and workload pressure (WISN ratio 0.45) were observed in the general-educational hospitals. In the specialized hospitals, the workload pressure was high (WISN ratio 0.49). The lowest shortage belonged to the private hospital. Based on our assessment, in all of the hospitals, nurses typically worked overtime due to high workload. The studied hospitals covered an average of 25% of their shortage with nursing overtime working. We noted that nurses were predominantly occupied with health service and supportive activities (≈90% of their time). CONCLUSIONS: Based on the WISN method, all of the hospitals faced nursing shortages from moderate to high. However, it would be essential to consider current labor market analysis based on accurate data to adopt appropriate policies in HRH planning.

Assessing the Iran Health System in Making Progress towards Sustainable Development Goals (SDGs): A Comparative Panel Data Analysis.

Background: Sustainable development goals' (SDGs) analysis can be caused a better understanding of factors contributing to access to health services and help shape policies to attain health goals. This review aimed to measure and compare the SDGs between Iran and selected categories. Methods: This study was a comparative cross-sectional study. We identified indicators of health status based on the SDGs report 2019. The status of SDGs indicators was compared in Iran to four categories, including selected countries with similar social, economic, and health status, six regions of the WHO, the average of each income level group. SPSS 20 and Excel 2019 software were used for descriptive data analysis. Results: The average life expectancy and healthy life expectancy were 75.7 years and 65.4 respectively in Iran. Iran's mortality rate in indicators named road traffic (32.1 per 100000 population), suicide (4.1 per 100000 population), and unintentional poisoning (1.2 per 100000 population) were higher than most of the categories. Iran's status in morbidity indicators had an approximately lower rate than all categories. Iran had full coverage in three immunization indicators like DTP3 immunization, MCV2 immunization, and PCV3 immunization, which was higher than all categories. Coverage of UHC in Iran (65%) was near to the global average (64%) and higher than the eastern Mediterranean Region (53%). Moreover, the prevalence of tobacco smoking (10.95%) and alcohol consumption (1%) were lower than global (6.4%) and the WHO regions (1.8%) average. Conclusion: Health status measurement is a trend that requires the collection, processing, analysis, and dissemination of data by a set of indicators. There are several weaknesses in reported data in the SDGs for some indicators, the data collection process should be noticed seriously by policymakers.

A Stepped-Wedge Cluster-Randomized Controlled Trial of Multi-interventional Approach for Fall Prevention.

BACKGROUND AND OBJECTIVES: Falls are one of the most common adverse events at hospitals that may result in injury and even death. They are also associated with raised length of stay (LOS) and hospitalization costs. This experiment aimed to examine the effectiveness of multiple interventions in reducing inpatient fall rates and the consequent injuries. METHODS: The present study was a stepped-wedge cluster-randomized controlled trial. It was done in 18 units in a public university hospital over 36 weeks. Patients included in this research were at risk of falls. Overall, 33 856 patients were admitted, of whom 4766 were considered high-risk patients. During the intervention phases, a series of preventive and control measures were considered, namely staff training; patient education; placement of nursing call bells; adequate lighting; supervision of high-risk patients during transmission and handovers; mobility device allocation; placement of call bell and safe guard in bathrooms; placing "fall alert" signs above patients' beds; nurses informing physicians timely about complications such as delirium and hypoxia; encouraging appropriate use of eyeglasses, hearing aids and footwear; keeping side rails up; and reassessing patients after each fall. The primary outcome was participant falls per 1000 patient-days. Secondary outcomes were fall-related injuries and LOS. RESULTS: The results revealed a decrease in fall rate (n = 4 per 1000 patient-days vs 1.34 per 1000 patient-days, incidence rate ratio (IRR) = 0.19 [95% confidence interval (CI), 0.14-0.26]; P = .001) and injuries (n = 2.4 per 1000 patient-days vs 0.79 per 1000 patient-days, IRR = 0.22 [95% CI, 0.15-0.32]; P = .001) in exposed compared with unexposed phases. There was not a significant difference in LOS (exposed mean 10.63 days [95% CI, 10.26-10.97], unexposed mean 10.84 days [95% CI, 10.59-11.09], mean difference = -0.13 [95% CI, -0.53 to 0.27], P = .52). CONCLUSIONS: This multi-interventional trial showed a reduction in falls and fall rates with injury but without an overall effect on LOS. Further research is needed to understand the sustainability of multiple fall prevention strategies in hospitals and their long-term impacts.

Recurrence of medical errors despite years of preventive measures: A grounded theory study.

BACKGROUND: Despite great efforts to improve patient safety, serious preventable medical errors continue to occur. Accurate rooting causes of error recurrence are essential for reviewing methods to prevent them. This study aimed to identify the main causes of the recurrence of medical errors despite their previous occurrence. MATERIALS AND METHODS: This qualitative study was performed using the grounded theory method, with theoretical sampling from April to July 2021, through semi-structured interviews with 25 experts and treatment staff of hospitals under the auspices of four universities of medical sciences in Iran. RESULTS: Four main parts were identified: 1) primary and secondary factors leading to the occurrence of errors, 2) error prevention policies, 3) causes of error repetition, and 4) contextual factors. CONCLUSION: The attention, seriousness, and commitment of health system managers, from top to bottom, to patient safety are essential for preventing error recurrence. The institutionalization of patient safety education from universities and attention to individual, social, and cultural factors should also be given serious attention.

A multi-phase approach for developing a conceptual model for human resources for health observatory (HRHO) toward integrating data and evidence: a case study of Iran.

BACKGROUND: Evidence-informed policymaking on human resources for health (HRH) has been directly linked with health system productivity, accessibility, equity, quality, and efficiency. The lack of reliable HRH data has made the task of planning the HRH more difficult in all settings. AIM: This study aimed to develop a conceptual model to integrate HRH data and evidence. METHODS: The current study is a mixed-method study conducted in three phases: a rapid literature review, a qualitative phase, and an expert panel. Firstly, the electronic databases were searched up to 2018. Then, in the qualitative phase, semi-structured interviews with 50 experts were conducted. Data analysis was performed using the content analysis approach. After several expert panels, the draft of the model was validated with 15 key informants via two Delphi rounds. RESULTS: Our proposed model embraces all dominant elements on the demand and supply side of the HRH in Iran. The conceptual model consists of several components, including input (regulatory system, structure, functions), educational system (pre-service and in-service education), health labor market structure, process (technical infrastructure), and output (productions, policymaking process). We considered networking toward sustainable interaction among stakeholders, and also the existence of capacity to integrate HRH information and produce evidence for actions. CONCLUSION: The proposed model can be considered a platform for developing a harmonized system based on the HRH data flow to evidence-informed decision-making via networking. We proposed a step-by-step approach for the sustainability of establishing a national human resources for health observatory (HRHO). The proposed HRHO model can be replicable and flexible enough to be used in different context domains.

Frequency and influential factors on occurrence of medical errors: A three-year cross-sectional study.

BACKGROUND: Despite efforts to improve patient safety, medical errors (MEs) continue to recur. Proper utilization of reported MEs can be effective in preventing their recurrence. This study investigated the errors reported in 3 years and examined the factors affecting them. MATERIALS AND METHODS: This descriptive analytical study was conducted using the errors reported in 20 hospitals under the auspices of one of Iran's medical universities from 2018 to 2020. All reported errors were investigated by an expert panel. RESULTS: In total, 6584 reported errors were grouped into four main categories based on the type of error. The highest reported errors were related to the management and treatment procedures. Analyses of the factors influencing medical errors revealed that 15 factors affected the occurrence of errors. An increasing trend of error was found in 9 of the 15 identified factors. Incorrect documenting of the physician's order in the nursing Kardex and noncompliance with the patient identification guide were the highest with 16.03 and 15.47%, respectively. CONCLUSION: The most identified factor was the incorrect registration of the physician's prescription on the nursing card; therefore, it seems that the use of computerized physician order entry should be considered. Furthermore, the mere existence and training of patient safety guides cannot help prevent errors. Not only should the underlying causes of errors be carefully identified and investigated but it also requires serious determination to follow the patient's safety instructions from the highest to the lowest levels of the health system.

Establishing an Observatory on Human Resources for Health (HRH) in Iran: A Qualitative Case Study.

Background: Many countries face critical challenges due to shortage and maldistribution of human resources for health (HRH). An HRH observatory can be used as a mechanism to monitor HRH issues and facilitate evidence-based decision-making. This study aims to identify the essential elements of an HRH observatory for Iran. Methods: This qualitative study was conducted through semi-structured interviews with 30 key informants over two months since May 2019. Purposeful and snowball sampling methods were used. Each interview lasted a minimum of 60 min. Data analysis was performed using the content analysis approach. Results: The essential elements for integrating HRH information were categorized into the following themes: organizational structure, partnership, prerequisites for implementing HRH observatory, data management, and evidence-informed policymaking. Our results propose a national HRH observatory for Iran consisting of steering, technical and research boards, and also stakeholders' and research networks under the governance of the ministry of health and medical education (MOHME). It is required to make a comprehensive plan in several steps and arrangements based on the country's situation. The stakeholder's network was identified based on their role in HRH development and production of information and evidence. The main aim of the HRH observatory considers monitoring trends in patterns of the HRH for evidence-based decision-making and policy development. Our results propose an evidence development network consisting of a national HRH Research Center (HRHRC) and a cooperative network formed by several medical universities. Conclusion: We provide a comprehensive approach to establishing a national HRH observatory. We consider the HRH observatory as a cooperative initiative among key stakeholders to produce knowledge in order to improve human resource policymaking. The proposed HRH observatory model emphasizes networking and stakeholder involvement.

Explanation of Socio-economic Inequality in Medicine Use: A Cross-sectional Analysis from Iran.

Background: Despite the favorable progress in the production of medicines, there is no significant access to these important health inputs among different socio-economic groups. Objectives: This study aimed to measure and explain socio-economic inequality in prescribed and non-prescribed medicine use in Iran. Methods: Data were obtained from a recent household survey on health services in Iran conducted in 2016. The Erreygers concentration index (ECI) was used to measure socio-economic inequality in the use of prescribed and non-prescribed medicines. In addition, Decomposition analysis was conducted to explain socio-economic inequality. Results: The ECI revealed pro-rich socio-economic inequality in prescribed medicine use (ECI = 0.067, SE = 0.010), indicating that prescribed medicine use was concentrated on the better-offs. On the other hand, this index showed pro-poor inequality in non-prescribed medicine use (ECI = -0.064, SE = 0.009). Decomposition analysis showed that economic status and place of residence were the main determinants of socio-economic inequality in prescribing medicines. These factors and the number of health care needs explained the majority of socio-economic inequality in non-prescribed medicine use. Conclusions: Despite previous positive beliefs, we found remarkable socio-economic inequality in the use of medicines in Iran. Facilitating access to pharmaceutical services for disadvantaged households and rural residents and promoting of national essential medicines list could be recommended against socio-economic inequality in the pharmaceutical market of Iran.

Cost-effectiveness of neuroimaging technologies in management of psychiatric and insomnia disorders: A meta-analysis and prospective cost analysis.

BACKGROUND: The optimal diagnostic strategy for patients with psychiatric and insomnia disorders has not been established yet. PURPOSE: The purpose of this study was to perform cost-effectiveness analysis of six neuroimaging technologies in diagnosis of patients with psychiatric and insomnia disorders. METHODS: An economic evaluation study was conducted in three parts, including a systematic review for determining diagnostic accuracy, a descriptive cross-sectional study with Activity-Based Costing (ABC) technique for tracing resource consumption, and a cost-effectiveness analysis using a short-term decision-analytic model. RESULTS: In the first phase, 93 diagnostic accuracy studies were included in the systematic review. The accumulated results (meta-analysis) showed that the highest diagnostic accuracy for psychiatric and insomnia disorders was attributed to PET (sensitivity of 90% and specificity of 80%) and MRI (sensitivity of 76% and specificity of 78%) respectively. In the second phase of the study, we calculated the cost of each technology. The results showed that MRI has the lowest cost. Based on the results in the model of cost-effectiveness sMRI ($ 50.08 per accurate diagnosis) and MRI ($ 58.54 per accurate diagnosis) were more cost-effective neuroimaging technologies. CONCLUSION: In psychiatric disorders, no single strategy was characterized by both low cost and high accuracy. However, MRI and PET scan had lower cost and higher accuracy for psychiatric disorders, respectively. MRI was the least costly with the highest diagnostic accuracy in insomnia disorders. Based on our model, sMRI in psychiatric disorders and MRI in insomnia disorders were the most cost-effective technologies.

Risk Factors for Falls in Hospital In-Patients: A Prospective Nested Case Control Study.

BACKGROUND: Patient falls are considered a challenge to the patient's safety in hospitals, which, in addition to increasing the length of stay and costs, may also result in severe injuries or even the death of the patient. This study aims to investigate the associations between risk factors among fallers in comparison with the control group. METHODS: A prospective nested case control study was performed on 185 patients who fell and 1141 controls were matched with the patients at risk of fall in the same ward and during the same time. This study was conducted in a university educational hospital in Tehran with 800 beds during a 9-month period. The data included demographics, comorbidities, admission details, types of medication, clinical conditions, and activities before or during the fall. The data was collected from clinical records, hospital information system, error reporting system and observations, and the interviews with the fallers, their families and care givers (physicians, nurses, etc). Data analysis was conducted through time-based matching using a multi-level analysis. RESULTS: In a multilevel model including patient-related, medication, and care-related variables, the factors that were significantly associated with an increased risk of patient falls included: longer length of stay (odds ratio [OR] = 1.01; CI=0.32 to 0.73), using chemotherapy drugs, sedatives, anticonvulsants, benzodiazepines, and angiotensin-converting enzyme (ACE) inhibitors, visual acuity (OR=6.93; CI=4.22 to 11.38), balance condition (OR= 6.41; CI=4.51 to 9.11), manual transfer aid (OR=8.47; CI=5.65 to 12.69), urinary incontinence (OR= 8.47, CI= 5.65 to 12.69), and cancer (OR=2.86, CI=1.84-4.44). These factors were found to be associating with more odds for a falling accident among patients. Several characteristics such as fall history (OR=0.48; CI= 1.003 to 1.02), poly-pharmacy (OR=1.37, CI=00.85 to 2.2), stroke (OR=0.94, CI= 0.44 to 2.02), and nurse to patient ratio (incidence rate ratio=1.01, CI=0.01 to 0.03) were not significantly associated with falling in hospitals. CONCLUSION: It seems that a combination of both patient-related factors and history of medication should be considered. Moreover, modifiable clinical characteristics of patients such as vision improvement, provision of manual transfer aid, diabetes control, regular toilet program, and drug modification should be considered during the formulation of interventions.

Pressure Ulcer Rate in Multidisciplinary Hospital Units After Multifactorial Intervention: A Stepped-Wedge, Cluster Randomized Controlled Trial.

OBJECTIVES: This study was conducted to measure the effectiveness of interventions in decreasing the rates of pressure ulcer in a general hospital setting. METHODS: Sixteen units in a general hospitals in Iran participated in this stepped-wedge, cluster randomized controlled trial during a 45-week study period. This trial has a one-sided crossover design from control to intervention. The units were randomly assigned fulfilling entry criteria. After the approval by the governing board of hospital, the manipulative intervention, in addition to usual care, was implemented on patients with a Braden criterion of 14 or less. The primary outcome was ulcer specification (grade and location of ulcer), and the secondary outcome was the length of hospital stay. RESULTS: A total of 18,900 patients were admitted during the 45-week study period in the study units, of whom approximately 20% (3846 patients) were identified as high risk according to the items of Braden scale criteria during the admission assessment by nurses. The highest rate of PUs (80%) was in grade 2, and 16% of patients had grade 3 and 4 PUs. The ulcers of the skin overlying the sacrum and hip areas were the most common sites in the patients under study. The rates of PU in the control, training, and intervention phases were 5.49 (4.72-6.34), 5.68 (3.82-8.15), and 4.62 (3.87-5.47), respectively, per 1000 patient-days. CONCLUSIONS: The multifaceted intervention proposed by the present study has succeeded in reducing rate of pressure ulcer. Multifaceted programs based on training are appropriate ways to provide essential information to patients and their caregivers, which result in improvement of their participation in therapeutic process. We recommend hospitals to use these findings as a quality improvement plan for decreasing the rate of pressure ulcer.

Preventing blood transfusion failures: FMEA, an effective assessment method.

BACKGROUND: Failure Mode and Effect Analysis (FMEA) is a method used to assess the risk of failures and harms to patients during the medical process and to identify the associated clinical issues. The aim of this study was to conduct an assessment of blood transfusion process in a teaching general hospital, using FMEA as the method. METHODS: A structured FMEA was recruited in our study performed in 2014, and corrective actions were implemented and re-evaluated after 6 months. Sixteen 2-h sessions were held to perform FMEA in the blood transfusion process, including five steps: establishing the context, selecting team members, analysis of the processes, hazard analysis, and developing a risk reduction protocol for blood transfusion. RESULTS: Failure modes with the highest risk priority numbers (RPNs) were identified. The overall RPN scores ranged from 5 to 100 among which, four failure modes were associated with RPNs over 75. The data analysis indicated that failures with the highest RPNs were: labelling (RPN: 100), transfusion of blood or the component (RPN: 100), patient identification (RPN: 80) and sampling (RPN: 75). CONCLUSION: The results demonstrated that mis-transfusion of blood or blood component is the most important error, which can lead to serious morbidity or mortality. Provision of training to the personnel on blood transfusion, knowledge raising on hazards and appropriate preventative measures, as well as developing standard safety guidelines are essential, and must be implemented during all steps of blood and blood component transfusion.

Evaluation of Effective Factors on the Clinical Performance of General Surgeons in Tehran University of Medical Science, 2015.

BACKGROUND & OBJECTIVE: Existence of doctors with high performance is one of the necessary conditions to provide high quality services. There are different motivations, which could affect their performance. Recognizing Factors which effect the performance of doctors as an effective force in health care centers is necessary. The aim of this article was evaluate the effective factors which influence on clinical performance of general surgery of Tehran University of Medical Sciences in 2015. METHODS: This is a cross-sectional qualitative-quantitative study. This research conducted in 3 phases-phases I: (use of library studies and databases to collect data), phase II: localization of detected factors in first phase by using the Delphi technique and phase III: prioritizing the affecting factors on performance of doctors by using qualitative interviews. RESULTS: 12 articles were analyzed from 300 abstracts during the evaluation process. The output of assessment identified 23 factors was sent to surgeons and their assistants for obtaining their opinions. Quantitative analysis of the findings showed that "work qualification" (86.1%) and "managers and supervisors style" (50%) have respectively the most and the least impact on the performance of doctors. Finally 18 effective factors were identified and prioritized in the performance of general surgeons. CONCLUSION: The results showed that motivation and performance is not a single operating parameter and it depends on several factors according to cultural background. Therefore it is necessary to design, implementation and monitoring based on key determinants of effective interventions due to cultural background.

Evaluation of Patient Safety Indicators in Semnan City Hospitals by Using the Patient Safety Friendly Hospital Initiative (PSFHI).

BACKGROUND: Nowadays, patient safety issue is among one of the main concerns of the hospital policy worldwide. This study aimed to evaluate the patient safety status in hospitals affiliated to Semnan city, using the WHO model for Patient Safety Friendly Hospital Initiatives (PSFHI) in summer 2014. METHODS: That was a cross sectional descriptive study that addressed patient safety , which explained the current status of safety in the Semnan hospitals using by instrument of Patient safety friendly initiative standards (PSFHI). Data was collected from 5 hospitals in Semnan city during four weeks in May 2014. RESULTS: The finding of 5 areas examined showed that some components in critical standards had disadvantages. Critical standards of hospitals including areas of leadership and administration, patient and public involvement and safe evidence-based clinical practice, safe environment with and lifetime education in a safe and secure environment were analyzed. The domain of patient and public involvement obtained the lowest mean score and the domain of safe environment obtained the highest mean score in the surveyed hospitals. CONCLUSION: All the surveyed hospitals had a poor condition regarding standards based on patient safety. Further, the identified weak points are almost the same in the hospitals. Therefore, In order to achieve a good level of all aspects of the protocol, the goals should be considered in the level of strategic planning at hospitals. An effective execution of patient safety creatively may depend on the legal infrastructure and enforcement of standards by hospital management, organizational liability to expectation of patients, safety culture in hospitals.

Effect size of contributory factors on adverse events: an analysis of RCA series in a teaching hospital.

BACKGROUND: One of the most important concerns of health care systems in the world is the patient safety issues. Root Cause Analysis is a systematic process for identifying root causes and contributory factors of problems or events. The objective of this study is to review RCA reports to determine the effect size of contributory factors on adverse events through an organizational perspective. METHODS: This study was conducted in a tertiary care teaching hospital in 2014. The process of root cause analysis was taken from National Patient Safety Agency framework. We calculated descriptive statistics to determine the frequency distribution of contributory factors on each adverse event. RESULTS: Having the process of 16 adverse events reviewed, 38 care or service delivery problems were identified which showed that 317 contributory factors and underlying causes had led to these problems. Accordingly, the most important contributory factors included the following: Task factors (20 %), education and training factors (16 %), communication factors (14 %), and team and social factors (13 %). CONCLUSIONS: RCA is an effective method of problem solving used for identifying the root causes of initial errors and finding ways to prevent the recurrences. In this study, lack of effective communication skills of nurses and other clinical staff when interacting with colleague and communicating with patients, failure to comply with health care provision standards, lack of adequate supervision on implementation of clinical guidelines and issues related to the organizational culture were the main determining factors which have been considered for implementing preventive measures with regard to the hospital specifications.