A Bottom-Up Approach to Understanding the Efficacy of Event-Analysis in Healthcare

Abstract

Root Cause analysis (RCA) is a widely implemented event-analysis tool in healthcare, used to improve pa-tient safety. Several studies have assessed the effectiveness of RCA solutions and provided recommenda-tions for improving the approach; however few have suggested a systematic approach to align RCA-based interventions with the realities of work practice in healthcare. In this study, semi-structured interviews were conducted with frontline healthcare staff (nurses, nurse managers and technicians) in order to assess their perspectives on the effectiveness and sustainability of RCA-based solutions in a large academic medical center. In general, preventive interventions such as physical environment or equipment changes were more effective and sustainable than reactive or passive measures such as reviews and compliance checks. A the-matic analysis of respondents’ narratives highlighted several issues related to the design and implementa-tion of various RCA-driven interventions. The analysis however, also revealed important facets of frontline medical practice, including the role played by staff in overcoming systemic hazards in order to increase pa-tient safety. These findings are discussed in the context of the emerging Resilience Engineering approach to safety in complex systems.