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

doi:10.1016/j.jradnu.2014.11.004

Journal of Radiology Nursing

Volume 34, Issue 1, March 2015, Pages 4-7

https://doi.org/10.1016/j.jradnu.2014.11.004 Get rights and content

Abstract

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.

Introduction

In its most basic form, root cause analysis is a structural manner of considering and analyzing serious adverse events. Initially, the concept of root cause analysis was used as an error analysis tool by the airline industry to determine the ultimate cause of a collision or near miss. This method of considering adverse events has now enjoyed widespread usage as a tool in numerous industries including health care. The most basic tenant of root cause analysis is to focus on system-based factors that increase the likelihood of an adverse event while avoiding the tendency to blame specific individuals for the adverse event.

When a sentinel event is identified, a root cause analysis must follow a specific protocol including data collection and reconstruction of the event that caused the adverse event. When done in a prescribed systematic manner, a root cause analysis can serve to prevent future harm by eliminating those factors that contributed to or promote the adverse event (Wu, Lipshutz, & Pronovost, 2008).

Section snippets

What is a sentinel event?

The Joint Commission (TJC), which accredits and certifies health care organizations and programs on safety and effective care, defines a sentinel event as being “an unexpected occurrence involving death or serious injury or psychological injury, or the risk thereof.” TJC goes on to define the phrase “or the risk thereof” to include any “process variation for which a recurrence would carry a significant chance of a serious adverse outcome.” These events are referred to as sentinel because they

Initiating the root cause analysis approach to sentinel events root cause analysis

When a sentinel event occurs, institutions have varying policies and procedures as to how soon the technique of root cause analysis should be commenced. In general, the analysis should begin as soon as possible while memories are still fresh.

Root cause analysis is a method of problem solving that attempts to identify the most rudimentary cause of the fault or problems that occurred (Huston, 2014). The philosophy behind root cause analysis is that only future problems can be averted by

The root cause analysis stages

The first step to an effective root cause analysis process begins with identifying the problem. This includes a complete non-emotionally charged definition of the process identified resulting in the sentinel event. Additionally, specific symptoms of the problem that may not be related to the specific sentinel event should be considered. For example, a near medication accident leading to the identification of a sentinel event may include a discussion of other problems related to medication

Case study

A 75-year-old patient (name: Hernandez) who was not fluent in English is brought to the radiology suite for a routine chest X-ray (CXR) based on recurrent incidents of bronchitis.

The patient was oriented three times and appeared very stable on his feet. The fall risk assessment was not communicated to the radiology department, and the radiology staff was unaware of a period of syncope experienced by the patient the day before.

While present in the radiology suite, the patient was asked whether

Incident Report

Name: Hernandez.

Location: Radiology room #1.

Age: 75 years old.

Assessment: Bleeding from back of head. Oriented to person only. Moaning in pain saying he needed to go to the bathroom.

Description of incident: Witnessed fall. Standing for CXR when patient attempted to walk. Legs buckled and patient fell striking head on X-ray table.

J. Baker, RN.

Signed.

Witness Statement (Nurse Murray)

Mr. Hernandez presented to the radiology department for a CXR to rule out pneumonia. No other history was available. On arrival, he was oriented

What happens after the root cause analysis process?

An individual should be identified to evaluate and make certain that the recommendations of the committee are instituted and integrated into the facility. Moreover, individuals in charge of management of the department should be held responsible for adequate follow-up and evaluation. Because change does not occur overnight, repeated reinforcement of the recommendations made by the committee will be necessary. As with any type of change, it can only be effective if all critical personnel accept

Discoverability

Health care providers understandably are concerned about the discoverability of the sentinel event process. The rules governing whether the records of a medical review committee and sentinel event committee are discoverable vary on a state-by-state basis. In any event, concerns regarding the discoverability of these documents should not circumvent an organization's desire to improve patient care by thoroughly analyzing risks. Although some states do not offer absolute protection to the sentinel

Conclusion

Sentinel event review is a useful tool in improving quality of care and should be integrated into all risk management programs at health care facilities. If properly implemented, the use of root cause analysis can dramatically decrease adverse events and promote patient safety.

Joan Cerniglia-Lowensen, JD, MS, BSN, member Pessin Katz Law, P.A., Towson, Maryland.

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A high PI incidence rate could indicate that systems are not functioning well, and that changes are needed to reduce reoccurrences of errors leading to adverse events. Root Cause Analysis (RCA) which originated in the airline industry [8], has been used for many years in different types of industries to respond to adverse events [9]. In 1996 the Joint Commission on Accreditation of Healthcare Organisations introduced this type of analysis into healthcare after a series of sentinel events resulting in patient harm [10], to investigate any errors leading to the adverse events.
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A variety of root causes were common amongst all the cases. These included both flaws in the system, such as poor equipment and inadequate educational programmes, as well as human factors such as a lack of basic routine care. No skin assessment was being performed (n = 0) apart from the assessment done on admission. Documentation of action planning when it comes to PI prevention was also missing (n = 0). It was identified that 7 patients were mobilized on admission while the others (n = 3) had a delay in mobilisation, due to some fragmentation in care. There was no documentation of patient and relative education on the prevention of PIs (n = 0). All the patients were provided with the right pressure redistributing mattress however, some mattresses were bottoming out. Some causes overlapped, with system defects like lack of protocols, equipment and tools pushing human errors to occur. This created a series of events leading to the adverse event. The identification of these factors helped to provide an understanding of the changes that are needed to reduce future harm and improve patient safety.
Recommendations were proposed to reduce contributing factors to the development of hospital-acquired PIs. These include audits to reinforce adherence to hospital guidelines, streamlining of the documentation system, investment in new equipment and improvements to educational programmes. The recommendations implemented resulted in a decreased incidence rate of HAPIs.
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