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

MedStar author(s):
Citation: BMJ Quality & Safety. 26(5):381-387, 2017 MayPMID: 27940638Institution: MedStar Institute for InnovationForm of publication: Journal ArticleMedline article type(s): Journal ArticleSubject headings: *Medical Errors/pc [Prevention & Control] | *Medical Errors/sn [Statistics & Numerical Data] | *Root Cause Analysis | Academic Medical Centers | Databases, Factual | Humans | Joint Commission on Accreditation of Healthcare Organizations | New York/ep [Epidemiology] | Patient Safety/st [Standards] | Postoperative Complications/ep [Epidemiology] | Safety Management | United StatesYear: 2016ISSN:
  • 2044-5415
Name of journal: BMJ quality & safetyAbstract: BACKGROUND: Despite 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 in an attempt to reduce adverse event rates; however, the outputs of this process have not been well studied in healthcare. This study aimed to examine the types of solutions proposed in RCAs over an 8-year period at a major academic medical institution.CONCLUSIONS: This study found that the most commonly proposed solutions were weaker actions, which were less likely to decrease event recurrence. These findings support recent attempts to improve the RCA process and to develop guidance for the creation of effective and sustainable solutions to be used by RCA teams.Copyright Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.METHODS: All state-reportable adverse events were gathered, and those for which an RCA was performed were analysed. A consensus rating process was used to determine a severity rating for each case. A qualitative approach was used to categorise the types of solutions proposed by the RCA team in each case and descriptive statistics were calculated.RESULTS: 302 RCAs were reviewed. The most common event types involved a procedure complication, followed by cardiopulmonary arrest, neurological deficit and retained foreign body. In 106 RCAs, solutions were proposed. A large proportion (38.7%) of RCAs with solutions proposed involved a patient death. Of the 731 proposed solutions, the most common solution types were training (20%), process change (19.6%) and policy reinforcement (15.2%). We found that multiple event types were repeated in the study period, despite repeated RCAs.All authors: Fairbanks RJ, Hettinger Z, Kellogg KM, Sellers CR, Shah M, Squires M, Wears RLFiscal year: FY2017Digital Object Identifier: Date added to catalog: 2017-05-24
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Journal Article MedStar Authors Catalog Article 27940638 Available 27940638

BACKGROUND: Despite 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 in an attempt to reduce adverse event rates; however, the outputs of this process have not been well studied in healthcare. This study aimed to examine the types of solutions proposed in RCAs over an 8-year period at a major academic medical institution.

CONCLUSIONS: This study found that the most commonly proposed solutions were weaker actions, which were less likely to decrease event recurrence. These findings support recent attempts to improve the RCA process and to develop guidance for the creation of effective and sustainable solutions to be used by RCA teams.

Copyright Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

METHODS: All state-reportable adverse events were gathered, and those for which an RCA was performed were analysed. A consensus rating process was used to determine a severity rating for each case. A qualitative approach was used to categorise the types of solutions proposed by the RCA team in each case and descriptive statistics were calculated.

RESULTS: 302 RCAs were reviewed. The most common event types involved a procedure complication, followed by cardiopulmonary arrest, neurological deficit and retained foreign body. In 106 RCAs, solutions were proposed. A large proportion (38.7%) of RCAs with solutions proposed involved a patient death. Of the 731 proposed solutions, the most common solution types were training (20%), process change (19.6%) and policy reinforcement (15.2%). We found that multiple event types were repeated in the study period, despite repeated RCAs.

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