Root Cause Analysis Process Research Articles

Achieving a 3-Star Society of Thoracic Surgery Lobectomy Ranking by Using Continuing Process Improvement, Lean Methodology, and Root Cause Analysis

Our purpose is to identify the metrics used by the Society of Thoracic Surgeons (STS) to rank lobectomy and to show our process to improve. This is a review of our STS data for lobectomy and our results using the process of root cause analysis and lean methodology to improve our outcomes. The STS metrics are 30-day mortality, pneumonia, adult respiratory distress syndrome, bronchopleural fistula, pulmonary embolus, initial ventilator support greater than 48 hours, reintubation and respiratory failure, tracheostomy, myocardial infarction, or unexpected return to the operating room. Sixteen of 231 programs (7%) were ranked 3-star over a 3-year period from July 2011 to June 2014. The most common root cause analysis was failure to escalate care. The lean and process improvements we employed that seemed to improve the results were increasing exercise before surgery, adding a respiratory therapist, eliminating Foley catheters and arterial lines to reduce infection and to increase ambulation, offering stereotactic radiotherapy for marginal patients, favoring left upper segmentectomy over left upper lobectomy, and performing 91% of the last 493 lobectomies via a minimally invasive platform. Our major morbidity complications from August 2003 to December 2014 fell from 9.5% to 5.3% (P = 0.001) and mortality decreased from 3.3% to 0.54% (P < 0.0001). The metrics the STS used to rank lobectomy programs are 30-day mortality and predominantly respiratory complications. Root cause analysis, lean methodology, and process improvements allowed us to improve our lobectomy patient outcomes over time and to achieve a 3-star ranking over a 3-year time frame. These results may be obtainable by others.

Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?

BackgroundDespite over a decade of efforts to reduce the adverse event rate in healthcare, the rate has remained relatively unchanged. Root cause analysis (RCA) is a process used by hospitals...

Medication Errors and Root Causes Analysis: Emerging Views and Practices in King Saud Medical City, Riyadh, Saudi Arabia

Background: Medication errors (MEs) are associated with significant morbidity and mortality, and huge cost worldwide. Medication errors are multifactorial and present in different forms with variable severity. Many tools are developed to analyze MEs for knowing the main etiological factor and preventing their occurrence. Objective: This mini-review narratively describes the emerging views and practices concerning MEs and root cause analysis (RCA) in King Saud Medical City (KSMC) supported by relevant international literature. Methods: Electronic searches of PubMed and Google Scholar using keywords were made to identify relevant articles published in English literature of the past 10 years. For illustrative purpose, three case scenarios of MEs with step-wise process of RCA were presented in this research. Results: A number of programs, orientation sessions, policies and procedures, ME reporting system, guidelines and action plan were developed to identify and prevent MEs, and RCA of MEs was the most important assessment tool to recognize the main causes underlying MEs in KSMC. Conclusion: Several programs, developed and implemented in KSMC over the past few years match with international evidence-based data, and RCA is an effective tool to detect, analyze and prevent MEs in this medical city. This mini-review calls for further research on MEs and root cause analysis in other hospitals of Saudi Arabia.

Effect size of contributory factors on adverse events: an analysis of RCA series in a teaching hospital.

BackgroundOne of the most important concerns of health care systems in the world is the patient safety issues. Root Cause Analysis is a systematic process for identifying root causes and contributory factors of problems or events. The objective of this study is to review RCA reports to determine the effect size of contributory factors on adverse events through an organizational perspective.MethodsThis study was conducted in a tertiary care teaching hospital in 2014. The process of root cause analysis was taken from National Patient Safety Agency framework. We calculated descriptive statistics to determine the frequency distribution of contributory factors on each adverse event.ResultsHaving the process of 16 adverse events reviewed, 38 care or service delivery problems were identified which showed that 317 contributory factors and underlying causes had led to these problems. Accordingly, the most important contributory factors included the following: Task factors (20 %), education and training factors (16 %), communication factors (14 %), and team and social factors (13 %).ConclusionsRCA is an effective method of problem solving used for identifying the root causes of initial errors and finding ways to prevent the recurrences. In this study, lack of effective communication skills of nurses and other clinical staff when interacting with colleague and communicating with patients, failure to comply with health care provision standards, lack of adequate supervision on implementation of clinical guidelines and issues related to the organizational culture were the main determining factors which have been considered for implementing preventive measures with regard to the hospital specifications.

Root Cause Analysis: Learning from Adverse Safety Events.

Serious adverse events continue to occur in clinical practice, despite our best preventive efforts. It is essential that radiologists, both as individuals and as a part of organizations, learn from such events and make appropriate changes to decrease the likelihood that such events will recur. Root cause analysis (RCA) is a process to (a) identify factors that underlie variation in performance or that predispose an event toward undesired outcomes and (b) allow for development of effective strategies to decrease the likelihood of similar adverse events occurring in the future. An RCA process should be performed within the environment of a culture of safety, focusing on underlying system contributors and, in a confidential manner, taking into account the emotional effects on the staff involved. The Joint Commission now requires that a credible RCA be performed within 45 days for all sentinel or major adverse events, emphasizing the need for all radiologists to understand the processes with which an effective RCA can be performed. Several RCA-related tools that have been found to be useful in the radiology setting include the "five whys" approach to determine causation; cause-and-effect, or Ishikawa, diagrams; causal tree mapping; affinity diagrams; and Pareto charts.

Root Cause Analysis Design and Its Application to Pharmacy Education

Objective. To evaluate third-year pharmacy students' ability to effectively design and apply root cause analysis (RCA) to a sentinel event and to analyze student responses for areas of proficiency and deficiency. Methods. This study involved a comprehensive review of RCA key assessments from 82 students in spring 2014. The performance assessments consisted of a review of each student's RCA worksheet and flow diagram as well as the 1-2 page narrative reflection. Results. The majority of students were able to successfully design an RCA, but had challenges with 3 components: fact-finding session, disclosure plan, and a flow diagram. Several students perceived challenges to conducting a formal RCA in certain health care settings, which included assembling an RCA team and gathering relevant facts, a lack of transparency/safe environment within organizations, and creating a plan for multiple/sequential errors. Conclusion. Most students were able to design an RCA process, but encountered difficulty with some components. Students also identified challenges in applying the approach in certain health care arenas.

Learning From Mistakes and Near Mistakes: Using Root Cause Analysis as a Risk Management Tool

A concept with its origins in aeronautics provides an excellent source of information to prevent future adverse events. A properly conducted root cause analysis investigation can prevent future adverse events and decrease potential liability for health care providers. This article will provide an overview of the process of root cause analysis and discuss its importance in improving quality of care.

Root Cause Analysis of Serious Adverse Events Among Older Patients in the Veterans Health Administration

Preventable adverse events are more likely to occur among older patients because of the clinical complexity of their care. The Veterans Health Administration (VHA) National Center for Patient Safety (NCPS) stores data about serious adverse events when a root cause analysis (RCA) has been performed. A primary objective of this study was to describe the types of adverse events occurring among older patients (age > or = 65 years) in Department of Veterans Affairs (VA) hospitals. Secondary objectives were to determine the underlying reasons for the occurrence of these events and report on effective action plans that have been implemented in VA hospitals. In a retrospective, cross-sectional review, RCA reports were reviewed and outcomes reported using descriptive statistics for all VA hospitals that conducted an RCA for a serious geriatric adverse event from January 2010 to January 2011 that resulted in sustained injury or death. The search produced 325 RCA reports on VA patients (age > or = 65 years). Falls (34.8%), delays in diagnosis and/or treatment (11.7%), unexpected death (9.9%), and medication errors (9.0%) were the most commonly reported adverse events among older VA patients. Communication was the most common underlying reason for these events, representing 43.9% of reported root causes. Approximately 40% of implemented action plans were judged by local staff to be effective. The RCA process identified falls and communication as important themes in serious adverse events. Concrete actions, such as process standardization and changes to communication, were reported by teams to yield some improvement. However, fewer than half of the action plans were reported to be effective. Further research is needed to guide development and implementation of effective action plans.

A Systems Approach to Patient Safety at the VA

A Systems Approach to Patient Safety at the VA

An evidence‐based toolkit for the development of effective and sustainable root cause analysis system safety solutions

Root cause analysis (RCA) after adverse events in healthcare is a standard practice at many institutions. However, healthcare has failed to see a dramatic improvement in patient safety over the last decade. In order to improve the RCA process, this study used systems safety science, which is based partly on human factors engineering principles and has been applied with success in other high-risk industries like aviation. A multi-institutional dataset of 334 RCA cases and 782 solutions was analyzed using qualitative methods. A team of safety science experts developed a model of 13 RCA solutions categories through an iterative process, using semi-structured interview data from 44 frontline staff members from 7 different hospital-based unit types. These categories were placed in a model and toolkit to help guide RCA teams in developing sustainable and effective solutions to prevent future adverse events. This study was limited by its retrospective review of cases and use of interviews rather than clinical observations. In conclusion, systems safety principles were used to develop guidelines for RCA teams to promote systems-level sustainable and effective solutions for adverse events.

E-RCA – collation and feedback of HCAI information

Root Cause Analysis (RCA) is an analysis method which aims to identify the root causes of preventable Health care associated infections (HCAIs). It is based on the concept that problems are best solved by attempting to address and take corrective action by eliminating the root causes rather than merely addressing the immediately obvious issues. The RCA tool developed by the UK Clean, Safe Care Team is useful helping to reduce MRSA (Methicillin resistant S. aureus) bacteraemias and C. difficile infections. We had been using RCA forms developed by the Clean, Safe Care Team until 2009 but felt that we needed to modify the content of the form to make it more effective and to develop a web based form to improve compliance with the RCA process.

Maintenance of Certification: The Profession's Response to Physician Quality

Maintenance of Certification: The Profession's Response to Physician Quality

ReCASTing the RCA: An Improved Model for Performing Root Cause Analyses

The root cause analysis (RCA) process is used to investigate adverse events. However, it may not reduce the risk of recurrence as effectively as intended. The authors propose adapting a risk prioritization and reduction process modeled after the Commercial Aviation Safety Team (CAST). The process involves the following: (a) increasing effectiveness of selected interventions by prioritizing each cause/contributing factor based on its role in the current sentinel event as well as in future events; interventions are then selected based on their ability to remediate the root causes/contributing factors and the likelihood of successful implementation; (b) measuring effectiveness of intervention implementation; and ( c) evaluating effectiveness of the interventions by measuring the rates of event recurrence, near misses, contributing factors, mitigating factors, and staff perceptions of risk. Teams that evaluate intervention effectiveness are independent of those that implement the intervention. This framework seeks to improve the RCA process and provide further insights into advancing patient safety.

The Effectiveness of Root Cause Analysis: What Does the Literature Tell Us?

Root cause analysis (RCA) is an analysis framework used in health care to determine the systemic causes and prevent recurrences of adverse events. It is required by The Joint Commission for reported events and by the Department of Veterans Affairs (VA) National Center for Patient Safety for qualifying events in VA medical centers. The evidence on RCA effectiveness in improving patient safety was reviewed. MEDLINE, Academic Search Premier, and the Cochrane Database were searched from database inception to September 2007. RCA case studies and articles that directly addressed the RCA framework were reviewed. Discussion of RCA did not emerge in the literature until the late 1990s, and there have been no controlled trials that test the RCA framework. Twenty-three articles describe the RCA process, 38 articles present RCA case studies, and 12 articles analyze weaknesses of the RCA framework. Eleven of the case studies measure RCA effectiveness, 3 using clinical outcome measures and 8 using process measures. All 11 articles report improvement of safety following RCA. RCA participants report the difficulty in forming causal statements and in developing/implementing corrective actions. Criticisms of RCA include the uncontrolled study design and participant biases. Overall, the limited literature on RCA effectiveness provides anecdotal evidence that RCA improves safety. At the same time, it highlights the numerous theoretical problems with the analytical framework. Formal studies at the system level and cost-benefit analysis are needed to determine the effectiveness of RCA. Structured publication of case studies will support shared knowledge and will provide benchmarks for improvement. Enrichment of the RCA literature body will enable reproducibility of improvement work, optimization of analysis, and validation of the framework itself.

Effectiveness and Efficiency of Root Cause Analysis in Medicine

PREVENTABLE MISTAKES ARE COMMON IN MEDICINE. FOR example, at 1 hospital, a patient received patientcontrolled analgesia (PCA), a combination of local anesthetic and narcotic. The medication was intended to be infused into the epidural space. Instead, a nurse inadvertently connected the tubing to an intravenous catheter, delivering potentially lethal anesthetic into the patient’s bloodstream. What followed were the nurse’s anguish and guilt and, almost as inevitably, the hospital’s root cause analysis (RCA). In the last decade, this process has become the main way medicine investigates mistakes and tries to prevent future mistakes. But like many innovations in medicine, RCA has never been evaluated for effectiveness. In the case mentioned above, the team identified flaws in the design of the epidural catheter, but thought that fixing those flaws was beyond their scope. Therefore, they made a recommendation they could implement: reeducating staff about the equipment’s use. In the end, despite a significant investment of resources, this solution did not remove the underlying hazard and had little effect outside the institution. No one had confidence that things were safer. Indeed, since 1999, the US Pharmacopeia has received 1600 reports of epidural-to-intravenous misconnection (MEDMARX data in file, USP 2007). Many of these incidents undoubtedly received their own RCAs, but the mistake continues to occur. Root cause analysis was originally developed in psychology and systems engineering to identify “the basic and causal factor(s) that underlie variation in performance.” It provides structure to the retrospective analysis of errors and has been used successfully for decades to uncover latent errors in high reliability organizations, such as aviation and nuclear power. Root cause analysis is now a familiar tool for hospitals and health care organizations and has helped to identify many problems and solutions. The RCA process is designed to answer 3 basic questions: what happened, why did it happen, and what can be done to prevent it from happening again? What is missing in medicine is a fourth question: has the risk of recurrence actually been reduced? The fact that it generally is not known whether risk has been reduced is causing concern that some of the considerable resources and efforts expended on RCA are being wasted.

The Veterans Affairs Root Cause Analysis System in Action

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.