Root Cause Analysis Process Research Articles

Demystifying the experience of participating in a root cause analysis: A hermeneutic phenomenological study

AimThis study aimed to explore registered nurses' experience participating in a root cause analysis (RCA) meeting because of their involvement in an adverse event. BackgroundAn RCA is the most common strategy used by organizations for adverse event investigations. Nursing healthcare professionals directly involved in an adverse event may be asked to participate in the RCA. However, no studies were found in the literature on their experience. MethodsSemi-structured audio-taped interviews were held with 13 registered nurses who participated in an RCA. Ricoeur's hermeneutic phenomenology guided data analysis. ResultsTwo structural elements represented the world of the nurses: 1) Learning about an RCA, and 2) being on the other side of the RCA table. Three phenomenological themes emerged: 1) anticipatory and embodied fear, 2) to speak or not to speak, 3) the aftermath. ConclusionNurses desire RCA education to assist in understanding and support from nurse leaders throughout the process. Healthcare organizations must create a safe and collaborative environment to empower nurses to speak up and have their voices heard during the RCA process. Implications for nursing leadersNurses want to participate in RCA meetings. However, leaders must demystify the RCA process for nurses through education and training.

Implementing an Electronic Root Cause Analysis Reporting System to Decrease Hospital-Acquired Pressure Injuries.

Hospital-acquired pressure injuries (HAPIs) continue to increase in comparison to other hospital-acquired conditions, despite advancements in prevention and wound care practices. In 2017, an interprofessional skin team (IST) was formed at an academic medical center to improve patient care and reduce HAPIs. Intentional wound, ostomy, continence (WOC) nurse rounding coupled with IST efforts steadily decreased HAPIs in the organization by 39%. In an effort to continue to improve care, a root cause analysis (RCA) of HAPIs was initiated in two intensive care units (ICUs) in October 2019. Using the Plan-Do-Study-Act model, two WOC nurses and a nursing professional development specialist from the IST developed the HAPIs RCA process. Rapid cycle process improvement demonstrated the need to transition from a paper form to an electronic process to increase accessibility for all nursing units and patients to benefit. In May 2020, an electronic reporting system for RCAs for HAPIs began. After implementation, there has been a 53.5% reduction in HAPIs over 2years. The standardized, electronic RCA process has resulted in improvement, dissemination of best practices, and fostering nonpunitive accountability for each unit's HAPIs.

INTEGRATIVE CURRICULLUM APPROACHES

The purpose of this collaborative social research also called action research action was to explore the perception of college professors from more than a dozen universities from different regions of post-conflict Somalia, their perception and openly teaching international electoral policy and practice (EPP), in the post-conflict Somalia’s classroom or in the public sphere. In addition, this action research study sought to develop understanding, meaning and root-cause analysis process in human performance in uncontrolled variations as the university lecturers displayed reluctance of teaching democracy related content for fear of public backlash due to the ideological divide. Methodologically, the author utilized Emerson, Fretz & Shaw (1995) observation protocol to gather data for analysis to reveal the perception of the 19 educators from 19 universities, and most importantly, on making informed decision on what the next step would be. The setting where the research took place was a training seminar on international electoral policy and practice (EPP), designed to teach the university lecturers from post-conflict Somalia. How the Somali educators can overcome the methodological, cultural and religious challenges when incorporating democracy related materials into the curricula in Somalia to boost the educational campaign on elections in Somalia which did not go to polls to freely elect a leader since 1967 elections. The author proposed The Culturally Competent Integrative Curriculum Approach to overcome the methodological dilemma.

Creating Patient Safety Team Members Through a Simulation-Based Interprofessional Root Cause Analysis Course.

The Accreditation Council for Graduate Medical Education Common Program Requirements require residents to participate in real or simulated interprofessional patient safety activities. Root cause analysis (RCA) is widely used to respond to patient safety events; however, residents may lack knowledge about the process. To improve clinicians' knowledge of the tools used to conduct an RCA and the science behind them, and to describe this course and discuss outcomes and feasibility. A flipped classroom approach was used. Participants completed 5 hours of pre-course work then attended an 8.5-hour program including didactic sessions and small group, facilitator-led RCA simulations. Pre- and post-surveys, as well as a 10-month follow-up on knowledge of and comfort with the RCA process were compared. Statistical significance was evaluated for matched pairs using a repeated measures analysis of variance. Of 162 participants trained, 59 were residents/fellows from 23 graduate medical education programs. Response rates were 96.9% (157 of 162) for pre-course, 92.6% (150 of 162) for post-course, and 81.5% (132 of 162) for 10-month follow-up survey. Most participants had never participated in an RCA (57%, 89 of 157) and had no prior training (87%, 136 of 157). Following the course, participants reported improved confidence in their ability to interview and participate in an RCA (P<.001, 95% CI 4.4-4.6). This persisted 10 months later (P<.001, 95% CI 4.2-4.4), most prominently among residents/fellows who had the highest rate (38.9%, 23 of 59) of participation in real-world RCAs following the training. The course led to a sustained improvement in confidence participating in RCAs, especially among residents and fellows.

Sentinel Events and Miscommunication What do we know in 2021: A Language and Social Psychology Framework

ABSTRACT The paper explored the extent to which hospital appointed official root cause analysis (RCA) panels consider antecedent and proximal events when they investigate communication related sentinel events (CRSEs) in hospitals. It also explored which CRSEs are most common in the hospital setting in Hong Kong and the communication modes most commonly associated with CRSEs. The data consisted of Risk Alert and Annual Report on SEs issued by the Hong Kong Hospital Authority from October 2007 to September 2017. Over the period studied, there were 379 reported sentinel events (SEs). In 186 of these SEs we identified communication as a contributing factor. We examined the RCA panels’ reports on contributing factors and subsequent recommendations in these 186 SEs and found that their recommendations only highlighted the proximal contributing factors and not antecedent factors that may be relevant. RCA panels most often recommended that communication should be enhanced or documentation improved. We propose that it is time to review the RCA process to recognize that many CRSEs may occur because of antecedent factors that result from the complex hospital organizational structure and its associated hierarchical culture. We suggest two ways forward, 1) applying a language and social psychology perspective to the investigations of CRSEs and, 2) the involvement of experts from different disciplines who can work with clinicians during RCA investigations.

How did we reform our out of control massive transfusion protocol program?

The massive transfusion protocol (MTP) is designed to quickly provide blood products at a fixed ratio for the exsanguinating patient. At our academic medical center, the frequency of MTP activation increased over 10-fold between 2008 and 2015, putting inordinate stress on our transfusion service. Gathering a large number of relevant stakeholders, we performed a multidisciplinary root cause analysis (RCA) in response to the acute clinical need to reform our MTP. Through the RCA, we identified four principal opportunities for improvement (OFI) associated with our MTP: education, stewardship, process improvement, and communication. Through the deployment of new approaches to each of these OFI, we reduced MTP activations, blood product waste, and transfusion service technologist stress. The MTP is amenable to improvement, and, although time intensive, the RCA process yields significant favorable effects: improving communication with colleagues, reducing stress within the transfusion service, and improving resource utilization. Activation of the MTP at our institution is now more aligned with its primary purpose: rapidly providing large quantities of blood products to exsanguinating patients.

A Cognitive Autopsy Approach Towards Explaining Diagnostic Failure

Diagnostic failure has emerged as one of the most significant threats to patient safety. It is important to understand the antecedents of such failures both for clinicians in practice as well is those in training. A consensus has developed in the literature that the majority of failures are due to individual or system factors or some combination of the two. A major source of variance in individual clinical performance is cognitive and affective biases; however, their role in clinical decision making has been difficult to assess partly because they are difficult to investigate experimentally. A significant drawback has been that experimental manipulations appear to confound the assessment of the context surrounding the diagnostic process itself. We conducted an exercise on selected actual cases of diagnostic errors to explore the effect of biases in the ‘real world’ emergency medicine (EM) context.Thirty anonymized EM cases were analysed in depth through a process of root cause analysis that included an assessment of error-producing conditions (EPCs), knowledge-based errors, and how clinicians were thinking and deciding during each case. A prominent feature of the exercise was the identification of the occurrence of and interaction between specific cognitive and affective biases, through a process called cognitive autopsy. The cases covered a broad range of diagnoses across a wide variety of disciplines. A total of 24 discrete cognitive and affective biases that contributed to misdiagnosis were identified and their incidence recorded. Five to six biases were detected per case, and observed on 168 occasions across the 30 cases. Thirteen EPCs were identified. Knowledge-based errors were rare, occurring in only five definite instances. The ordinal position in which biases appeared in the diagnostic process was recorded. This experiment provides a baseline for investigating and understanding the critical role that biases play in clinical decision making as well as providing a credible explanation for why diagnoses fail.

Root cause analysis – what do we know?

Root cause analysis (RCA) provides audit firms, regulators, policy makers and practitioners the opportunity to learn from past adverse events and prevent them from reoccurring in the future, leading to better audit quality. Recently approved regulations (ISQM1) make RCA mandatory for certain adverse events, making it essential to learn how to properly conduct an RCA. Building on the findings and recommendations from the RCA literature from other industries where RCA practice is more established such as the aviation and healthcare industries, audit firms can implement an adequate and effective RCA process. Based on the RCA literature, I argue that audit firms would benefit from a systems-based approach and establishing a no-blame culture.

Improvement of cooling time performance in TAD® 20t mixing vessel using root cause analysis and PDCA cycle in TAD® 20t mixing vessel product maturity

The process of continuous improvement in product design portfolios uses the PDCA cycle, while the iteration process is carried out to obtain optimal and validated results and to increase the level of maturity of the product. Eliminating defects in TAD® installed at PT. YYY is able to improve the “cooling time” performance. Improved cooling time performance also resolves problems that occur in the production of Hair Care at PT. YYY and improve global product efficiency. On the other hand this also completes the “Problem Resolution Customer System” ticket on behalf of PT. YYY The solution produced has been through several discussions ranging from brainstorming all parameters that cause problems, the process of gathering RCA (Root Cause Analysis) to look for the potential impact of all parameters found during the brainstorming process through Fish Bond Diagram analysis techniques to obtain potential solutions. In terms of product portfolio management also minimizes the impact of this happening again in the future which can have negative effects related to the company’s name, additional costs for product repairs that increase problems and minimize losses from customers

Contributing factors to severe complications after liver resection: an aggregate root cause analysis in 105 consecutive patients

BackgroundThe aggregate root cause analysis (AggRCA) was designed to improve the understanding of system vulnerabilities contributing to patient harm, including surgical complications. It remains poorly used due to methodological complexity and resource limitations. This study aimed to identify the main patterns contributing to severe complications after liver resection using an AggRCA.MethodsThis was a retrospective qualitative study aimed to identify the main patterns contributing to severe complications, defined as strictly higher than grade IIIa according to the Clavien-Dindo classification within the first 90 days after liver resection. All consecutive severe complications that occurred between January 1st, 2018 and December 31st, 2019 were identified from an electronic database and included in an AggRCA. This included a structured morbidity and mortality review (MMR) reporting tool based on 50 contributory factors adapted from 6 ALARM categories: “Patient”, “Tasks”, “Individual staff”, “Team”, “Work environment”, and “Management and Institutional context”. Data resulting from individual-participant root cause analysis (RCA) of single-cases were validated collectively then aggregated. The main patterns were suggested from the contributory factors reported in more than half of the cases.ResultsIn 105 consecutive liver resection cases, 15 patients (14.3%) developed severe postoperative complications, including 5 (4.8%) who died. AggRCA resulted in the identification of 36 contributory factors. Eight contributory factors were reported in more than half of the cases and were compiled in three entangled patterns: (1) Disrupted perioperative process, (2) Unplanned intraoperative change, (3) Ineffective communication.ConclusionA pragmatic aggregated RCA process improved our understanding of system vulnerabilities based on the analysis of a limited number of events and a reasonable resource intensity. The identification of patterns contributing to severe complications lay the rationale of future contextualized safety interventions beyond the scope of liver resections.

Improving the Effectiveness of Root Cause Analysis in Hospitals

Improving patient safety within hospitals has become a major focal point for administrative and clinical action. Root Cause Analysis (RCA) is an analytical tool used by hospitals in quality improvement and patient safety efforts. While hospitals have widely embraced RCA, the effectiveness of the RCA process has been questioned in recent years. Based on a literature review and feedback from practicing administrators, this paper identifies current barriers to the effectiveness of the RCA process, and suggests actions to overcome them. A more effective RCA process will enable hospitals to establish a safer and more trustworthy care environment for patients.

Improving Root Cause Analysis of Patient Safety Events in Radiology.

Patient safety events occur in health care, and root cause analysis (RCA) meetings held after these incidents often reveal valuable insights into systemic barriers between optimal processes or stated policies and actual practice, providing critical opportunities for improvement. The patient safety team that facilitates RCA meetings in the radiology department at the authors' institution received feedback suggesting dissatisfaction with the RCA process. The team followed a structured process improvement framework to analyze the root causes of this dissatisfaction and create a better system. Using a post-RCA survey to target satisfaction scores as an improvement goal, the team successfully increased participant and facilitator satisfaction levels with sustained results. The patient safety team applied structured process improvement methodologies to their own daily work, learning lessons about measuring difficult processes and choosing appropriate metrics, the benefits of standardized work, and how to continuously improve a quality program. In the course of improving the satisfaction of employees participating in the RCA process, a more robust, continuously improving patient safety program has emerged to enhance the ability of those within the department to report, learn from, and hopefully prevent patient safety events in the future.©RSNA, 2020.

107. GETTING TO THE ROOT CAUSE: RESIDENT ENGAGEMENT IN A MORBIDITY, MORTALITY, &amp; IMPROVEMENT CURRICULUM WITHIN A LARGE PEDIATRIC TRAINING PROGRAM

Residents are exposed to medical errors during their training. The ACGME emphasizes the importance of patient safety and medical error analysis in a residency curriculum. Understanding root cause analysis (RCA) is an important component of a morbidity, mortality, and improvement (MMI) curriculum, enriching patient safety education. The objectives are to (1) engage residents in a mock RCA, (2) increase resident comfort in reporting medical errors, and (3) increase resident awareness of patient safety opportunities. Our MMI curriculum incorporated a mock-RCA workshop which highlighted a medical error that occurred due to poor patient hand-off. Residents assumed multiple roles (including that of chief quality officer) and were guided through an RCA. They identified the safety event, deviations from standard of care, and corrective actions to mitigate recurrence. Using a 5-point Likert scale survey, we assessed residents on their understanding of the RCA process, confidence in identifying safety events and deviations in care, willingness to report a medical error, and perceived ability to identify QI opportunities in the workplace. 100% strongly agreed or agreed that they had a better understanding of the RCA process (n = 20). 95% either strongly agreed or agreed that they felt confident in identifying safety events and deviations in care. Regarding likelihood to self-report a medical error or one made by a colleague, 95% strongly agreed or agreed with both statements. All residents strongly agreed or agreed with their ability to identify QI opportunities in day-to-day patient care. Lastly, 85% either strongly agreed or agreed that they had become more actively interested in participating in a QI project involving patient safety. Medical errors provide opportunities for residents to learn and take corrective actions. An MMI curriculum, focused through the lens of an RCA, is an opportunity for residents to gain a better understanding of how medical errors are identified and engage residents in QI science on a hospital-wide level.

Going Down the Tubes: A Multidisciplinary Root Cause Analysis on a Patient Safety Event Involving Delayed Transfusions

Background The pneumatic tube delivery system (PTDS) has been an integral part of blood bank (BB) operations at our institution ever since its implementation in the early 2000s. Its reliable performance is essential for rapid and accurate delivery of blood products, impacting patient safety and product integrity. However, malfunctioning operational events are not uncommon given PTDS complexity and hospital-wide utilization. In 2018, 33 of 285 (12%) blood products were wasted due to PTDS events at our institution. Here we review the root cause analysis (RCA) of a patient safety event involving delayed transfusions and a wasted blood product causing temporary harm to two patients. Methods Two patients, both hospitalized on the same floor, simultaneously experienced significant delays in red blood cell (RBC) transfusions. One patient with active bleeding experienced a 2-hour delay and another patient with anemia experienced a 50-minute delay before appropriate transfusion occurred. The two patients did not receive their transfusions until their nurses physically retrieved RBC units from the BB. An incident report was filed by a floor nurse, which prompted a RCA involving the laboratory quality and patient safety team, the BB, the hospital maintenance department overseeing the PTDS, and the information systems service controlling programming of the PTDS. Results Operational challenges surrounding the PTDS were central to the multiple root causes identified (see Table). RBC units sent to the floor from the BB were electronically directed to another floor or returned to the BB, which resulted in a waste of one RBC unit. Despite multiple potential contributing factors identified, deeper investigation did not uncover evidence for any specific root cause and the electronic tube transaction history showed normal PTDS operations during the time of the incident, with all transactions appearing as successfully completed within expected timeframes. Neither of the patients involved in this safety event experienced permanent harm. The findings of this investigation were reviewed at our departmental Pathology Morbidity and Mortality conference together with stakeholders from hospital maintenance. Conclusion The root causes for PTDS technical malfunctioning leading to this safety event remain uncertain despite a collaborative RCA. This multidisciplinary retrospective RCA process, however, provided an opportunity for greater awareness of the complex mechanism of the PTDS, promoted awareness of the roles of the various stakeholders involved, and fostered interdepartmental collaboration to prevent future patient safety incidents using quality improvement principles. Table Disclosures No relevant conflicts of interest to declare.

Patient Safety/Quality Improvement Primer, Part II: Prevention of Harm Through Root Cause Analysis and Action (RCA2).

With increasing emphasis on patient safety/quality improvement, health care systems are mirroring industry in the implementation of root cause analysis (RCA) for the identification and mitigation of errors. RCA uses a team approach with emphasis on the system, as opposed to the individual, to accrue empirical data on what happened and why. While many otolaryngologists have a broad understanding of RCA, practical experience is often lacking. Part II of this patient safety/quality improvement primer investigates the manner in which RCA is utilized in the prevention of medical errors. Attention is given to identifying system errors, recording adverse events, and determining which events warrant RCA. The primer outlines steps necessary to conduct an effective RCA, with emphasis placed on actions that arise from the RCA process through the root cause analysis and action (or RCA2) rubric. In addition, the article provides strategies for the implementation of RCA into clinical practice and medical education.

Root Cause Analysis for Hospital-Acquired Pressure Injury.

Root cause analysis (RCA) is a systematic process for identifying the causes of an adverse occurrence or combined with an approach for a response designed to prevent recurrences. This method may be used for continuous quality improvement in a facility or health system. Root cause analysis can aid nurses and hospital risk managers to determine how the system can improve to reduce the number and severity of pressure injuries. The process of RCA begins with being certain the wound is a pressure injury using differential diagnoses of similar appearing skin disease and injury, followed by an examination of the processes of care (human roots) for missed actions or inactions that are linked to development of a particular pressure injury. The final step of RCA is a critical examination of the system (including people and processes) to look for modifiable trends or patterns are identified that are used to prevent recurrences.

Employing a Root Cause Analysis Process to Improve Examination Quality

Multiple-choice question (MCQ) examinations represent a primary mode of assessment used by medical schools. It can be challenging for faculty to produce content-aligned, comprehensive, and psychometrically sound MCQs. Despite best efforts, sometimes there are unexpected issues with examinations. Assessment best practices lack a systematic way to address gaps when actual and expected outcomes do not align. The authors propose using root cause analysis (RCA) to systematically review unexpected educational outcomes. Using a real-life example of a class's unexpectedly low reproduction examination scores (University of Michigan Medical School, 2015), the authors describe their RCA process, which included a system flow diagram, a fishbone diagram, and an application of the 5 Whys to understand the contributors and reasons for the lower-than-expected performance. Using this RCA approach, the authors identified multiple contributing factors that potentially led to the low examination scores. These included lack of examination quality improvement (QI) for poorly constructed items, content-question and pedagogy-assessment misalignment, and other issues related to environment and people. As a result of the RCA, the authors worked with stakeholders to address these issues and develop strategies to prevent similar systematic issues from reoccurring. For example, a more robust examination QI process was developed. Using an RCA approach in health care is grounded in practice and can be easily adapted for assessment. Because this is a novel use of RCA, there are opportunities to expand beyond the authors' initial approach for using RCA in assessment.

Development of Korean Root Cause Analysis Software for Analyzing Patient Safety Incidents

Purpose The purpose of this study is to develop the Korean root cause analysis (RCA) software that can be used to systematically investigate underlying causes for preventing or reducing recurrence of patient safety incidents. Methods We reviewed the existing guidelines and literatures on the RCA in order to figure out the RCA process. Also we examined the existing RCA softwares for investigating patient safety incidents to design the contents and interface of the RCA software. Based on the results of reviewing literatures and softwares, we developed a draft version of the Korean RCA software that can be easily used in Korean hospital settings by RCA teams. Results The Korean RCA software consisted of several modules, which are modules for identifying patient safety incidents, organizing RCA team, collecting and analysing data, determining contributory factors and root causes, developing the action plans, and guiding evaluation. Conclusion The Korean RCA software included optimized RCA process and structured logic for cause analysis. Thus even beginners in RCA are expected to easily use this software for investigating patient safety incidents. As software has been developed with the public financial support, it will be distributed free of charge. We hope that it will contribute to facilitating patient safety improvement activities in Korea. Key words: Root cause analysis ㆍ Software ㆍ Patient safety

An event-driven dynamic cross-layer business process compliance monitoring and analysis framework

Any business process life-cycle should be monitored for adherence to compliance, so as to detect, analyse and recover from anomalies. Whenever a business process implemented as service-based system (SBS) deviates from compliance obligations, it is imperative to overcome anomalies so that the process is not adversely affected. This necessitates a monitoring and root-cause analysis process. Performance of the SBS is determined by factors such as goals and objectives of business layer; output data, execution time and number of services in service layer; processing load, storage capacity of the infrastructure layer. Current approaches are considered inadequate as they observe and verify adherence to properties in any one of the layers of the SBS. We propose a monitoring and root-cause analysis framework capable of congregating and correlating events from all layers of the SBS. The prototypical implementation based on event paradigm is non-invasive and introduces no overhead to the system under consideration.

Deep Network Analyzer (DNA): A Big Data Analytics Platform for Cellular Networks

In this paper, we present deep network analyzer (DNA), a big data analytics platform for anomaly detection (AD) and root cause analysis (RCA) in mobile wireless networks. DNA is motivated by the growing scale and complexity of cellular networks along with the lack of advanced big data analytics tools for effective network management. It abstracts the RCA process into two modules, namely rule (fingerprint) learning and the module of AD and fingerprint matching. We first develop a rare association rule mining method to learn the symptoms of network anomalies and to build a fingerprint knowledge database from the historic data. Then a statistical machine learning approach is employed to identify the anomalies within the incoming dataset collected via various probes in the network and map the fingerprints of the detected anomalies to the rules in the knowledge database. The DNA platform has been tested using the real production data from the field and has been shown to be a highly effective platform for AD and RCA for large-scale cellular systems serving tens of millions of mobile users.