Root Cause Analysis

WeCare Morning Report #6

Tuesday, April 21st, 7:30am

2450 Riverside Ave

Minneapolis, MN

We'll meet on the 6th floor of Masonic (6140) for our morning report focused on Patient Safety. This month we will be going through a Mock Root Cause Analysis. All fellows and residents are encouraged to attend.

Overview

A patient safety event is an event, incident, or condition that could have resulted or did result, in harm to a patient that is not related to the natural course of their underlying disease[a]. When a patient safety event does lead to harm to a patient, it falls into the category of events called adverse events. The Joint Commission defines "sentinel events", as the subset of adverse events that lead to death, permanent harm, or severe temporary harm and require investigation. Most healthcare systems use a Root Cause Analysis to investigate sentinel events.

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Definition

An RCA is an evidence based process by which an inter-professional team seeks to understand all the possible factors associated with an incident by asking what happened, why it happened and what can be done to prevent it from happening again[b]. It usually seeks to look at the entire system rather than individual performance though it should involve the providers most familiar with the event. It is as impartial as possible and should be facilitated by a trained healthcare professional.

Areas an RCA may investigate:


  • Communication: Was information lost in communication between staff members or patient care areas?
  • Environment: Has there been an environmental risk assessment?
  • Equipment: Was equipment functioning properly and staff trained to use it? Was there any information technology that was difficult to use?
  • Safeguards: Were there existing barriers (warnings, safety stops) in place that failed to prevent this event from happening? Are there additional controls that could be added?
  • Rules (policies and procedures): Are there policies in place that relate to this event? Was this event reported and addressed in an appropriate and non-punitive manner?
  • Training and scheduling: Were the personnel involved adequately trained to perform the tasks they were assigned? Does their schedule allow for appropriate self-care and sleep in order to perform tasks safely?[c]

Conclusion

All patient safety events should be reported via an event reporting system, such as iCare at UMMCH. Sentinel events are investigated using Root Cause Analysis, a tool used to identify causes of the event and ways to prevent recurrence. A hospital may choose to investigate other events that fall outside the definition of a sentinel event as an "elective" RCA. Recommendations resulting from an RCA should be clear and realistic enough to be implemented in a timely manner.

References

[a] Fairview Health Services. Policy: Sentinel Event/Patient Safety Event: Organizational Response to. Re-approved March 2015. Online at http://intranet.fairview.org/Policies/Category/AdministrationLeadership/S_047136. Accessed April 14, 2015.

[b]World Health Organization. Root Cause Analysis. 2012. Online at http://www.who.int/patientsafety/education/curriculum/Curriculum_Tools/en/index1.html, Accessed April 14, 2015.

[c] VA National Center for Patient Safey. Root Cause Analysis. Online at http://www.patientsafety.va.gov/professionals/onthejob/rca.asp. Accessed April 13, 2015