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

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Citation: Journal of Healthcare Risk Management. 33(2):11-20, 2013.PMID: 24078204Institution: MedStar Institute for InnovationForm of publication: Journal ArticleMedline article type(s): Journal ArticleSubject headings: *Medical Errors/pc [Prevention & Control] | *Patient Safety/st [Standards] | *Root Cause Analysis/mt [Methods] | *Safety Management/mt [Methods] | Databases, Factual | Humans | Interviews as Topic | Qualitative Research | Retrospective Studies | Root Cause Analysis/st [Standards] | Safety Management/og [Organization & Administration] | Safety Management/st [Standards]ISSN:

1074-4797

Name of journal: Journal of healthcare risk management : the journal of the American Society for Healthcare Risk ManagementAbstract: 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. 2013 American Society for Healthcare Risk Management of the American Hospital Association.All authors: Bisantz AM, Fairbanks RJ, Hegde S, Hettinger AZ, Lewis VL, Rackoff AS, Wears RL, Wreathall JDate added to catalog: 2014-08-21

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Holdings
Item type	Current library	Collection	Call number	Status	Date due	Barcode
Journal Article	MedStar Authors Catalog	Article		Available		24078204

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. 2013 American Society for Healthcare Risk Management of the American Hospital Association.

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