Utilizing Root Cause Analysis (RCA)
Root cause analysis is useful for invesigating errors. For example, a
resident gives a medication injection to the wrong patient; a resident
attempts a thoracentesis on the "wrong side", or a resident fails to
appropriately sign out a patient during "patient handoff".
When there is a serious, unexpected occurance (or "near miss"), this is
referred to as a "sentinel event". To maintain patient safety, the Joint
Commission on Accreditation of Healthcare Organizations (JCAHO) expects
hospitals to identify and respond to such sentinel events by performing a
root cause analysis (RCA), implement improvements, and monitor
effectiveness.
The JCAHO patient safety standards mandate that hospitals conduct such a
root cause analysis. The RCA is not a single tool or strategy, but many
tools used in combination to identify factors which caused a "performance
variation" (error). This type of approach is adapted from industry where
Outcomes are expected to fall within defined parameters, and where
Performance Variations can usually be tracked back to certain Actions and
Processes. Particular attention is usually given to the Processes which
allowed the Sentinal Event to occur. Typically the RCA includes the
following
steps:
I. What happened? (Sentinal Event) What are the details of event?
When did it occur?
What was impacted?
II. Why did it happen? (The Process) What are the steps in the process
as it is currently designed?
III.What were the most (Human factors)
proximate factors? (Equipment factors)
(Environmental factors)
(Other)
In Summary: Root cause analysis uses evidence to guide the anlysis, not
conjecture or opinions, and it recognizes that humans are involved in all
failure processes. However, it does not allow blame to be the ending point.
Rather, the RCA helps to show why the system allowed an individual to make an
error, and what improvements might prevent a repeat of that error. For
example, the anonymous reporting system for possible medication errors that
we use has led to many improvements in how medications are ordered and
delivered.
References:
1. www.jcaho.org
2 Ammerman M. The Root Cause Analysis Handbook: A simplified approach to
identifying, correcting and reporting workplace errors.
3. Andersen B. Business Process Improvement Toolbox
