Well-trained, highly-educated healthcare professionals strive each day to provide the best and safest care for their patients. However, despite ongoing efforts, preventable medical errors persist as the number three cause of death in the United States, following only behind heart disease and cancer.¹

Beyond what and why

When medical errors occur, the natural reaction may be to determine which employees were involved and to terminate their employment. The assumption is the employees did something wrong. Though that may be the case, there is no guarantee that the same incident will not occur again, with other employees involved, unless the healthcare facility digs deeper to understand exactly what happened, why it happened, and what needs to change to prevent future mistakes.

This is where root cause analysis comes in. The American Society of Risk Management defines the root cause analysis (RCA) process for the healthcare industry as a “systematic analysis of an event or near miss that has occurred within the healthcare setting.

Understanding what happened is only one piece of the puzzle. To minimize the likelihood that similar mistakes will be made again, healthcare facilities need to implement sustainable changes to processes, policies, and environment. Analysis plus action will help ensure safer patient care and working conditions for staff.

– MARYBETH RHODES RN, MN, CPHRM,

Risk Management Consultant,

The Hanover Insurance Group

When performing RCA, organizations should consider the goals they want to achieve. Common expectations of RCA include:

• Identifying and implementing sustainable systems-based improvements that provide safer patient care
• Identifying methodologies and techniques that will lead to more efficient and effective use of RCA
• Promoting the utilization of tools to evaluate the RCA process so that significant errors or flaws are realized and remedied prior to implementing the action items
• Employing RCA as a focused review of the systems and processes involved in the delivery of healthcare and not on individual action.

Root cause analysis should not be a tool used to discipline employees involved. To do so would impede a culture of safety and decrease the chance of errors being brought forth in the future.

 

Learning from mistakes

Root cause analysis at a glance³

• Identify the problem
• Select team conduct investigation
• Identify possible factors
• Identify root cause
• Define and implement action plan
• Monitor and assess results

When conducted properly, RCA can help us learn from our mistakes. How organizations handle RCA should be documented and reviewed annually. Keys to success include:

• Support and involvement of leadership team
• Documentation of what incidents should go through RCA
• Starting RCA within 72 hours of an incident
• Establishment of a four-to six-person team, including at least one person who has expertise in the RCA process
• A consistent approach to the investigation, including utilization of such tools as interviews, flow charts, diagrams, barriers, five whys, action hierarchy, accountability and measurement
• Determination of actions to be taken and timing
• Ongoing measurement of the changes and improvements
• Feedback to staff, patient, and family on findings⁴

Given how busy all healthcare professionals are, it is tempting to forego RCA, but given what is at stake — patient and staff safety — it is advisable to take the time and understand what caused a medical error. If not, it will eventually re-occur.

Sources:

1. McCann E. Deaths by Medical Mistakes Hit Records. Healthcare IT News. July 18, 2014. Accessed February 24, 2017.

2. World Health Organization, 10 Facts on Patient Safety. Fact Files. Accessed February 24, 2017.

3. Six Sigma What is Root Cause Analysis

4. Root Cause Analysis Playbook-An Enterprise Risk Management Approach and Implementation Guide. ASHRM. 2015

5. RCA2 Improving Root Cause Analyses and Actions to Prevent Harm, Version 2. National Patient Safety Foundation. January 2016

6. United for Patient Safety Progress Report 2014-2015. National Patient Safety Foundation. February 2016.

7. Shining A Light Safer Health Care Through Transparency. The National Patient Safety Foundations Lucian Leape Institute. Report of the Roundtable on Transparency. 2015

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126-10056 (9/17)              LC 2017-352