The Veterans Affairs Root Cause Analysis System in Action

Abstract

The patient safety program in the Department of Veterans Affairs (VA) began in 1998, when the National Center for Patient Safety (NCPS) was established to lead the effort on a day-to-day basis. NCPS provides the structure, training, and tools, and VA facilities provide front-line expertise, feedback about the process, and root cause analysis (RCA) of adverse events and close calls. Facility patient safety managers determine the disposition of adverse events and close calls occurring at their facilities. They use a safety assessment code (SAC) to prioritize the actual and potential severity and frequency of an event. BEFORE-AND-AFTER STUDY: Before the new RCA system was implemented in 2000, the VA used another adverse event reporting system, focused review (FR). A comparison of the two processes indicates that the RCA process has shifted analyses of adverse events toward a human factors engineering approach-entailing a search for system vulnerabilities rather than human errors and other less actionable root causes. Two case examples--on hazards in the magnetic resonance imaging (MRI) room and on a cardiac pacemaker malfunction--illustrate how the RCA system works in actual operation. The cases illustrate that broadly applicable, high-impact actions can result from a thorough RCA process. NCPS monitors the quality and completeness of RCAs through the immediate review and feedback process. Still to be investigated is the effectiveness of RCA actions addressing the hypothesized root causes and contributing factors of the close calls and adverse events.