A significant percentage of adverse events and complications that occur in the hospital setting may be owing to medical errors. When mistakes occur, the hospital should not commit a further mistake by not knowing how to handle the mistakes. The processes of root cause analysis (RCA) are a way of responsibly handling medical errors. RCA is a powerful method of investigating medical errors, and investigation is the precursor of prevention. Medical errors are generally considered to be human error, and to reduce human error, an organization must employ better trained and better qualified personnel.
But human factor is only a part of the story, although usually the most apparent part. The basic assumption behind RCA is that medical errors mostly occur due to problems in the overall system of healthcare delivery, which sets up the situation for doctors and nurses to make mistakes. The system can always be changed and needs to be continually improved wherever there is a scope for improvement. Blaming individuals is the most natural reaction of people when horrible medical mistakes come to light.
While this is completely understandable, punishing and stigmatizing the individuals is not the scientific way to go about it. To be able to prevent medical errors from happening in the future, we must investigate and find out where the weaknesses of the system lie. Blaming the individuals is an easy out, but it could be often counterproductive because by focusing on the individual, the system that let the individual make the mistake in the first place is allowed to remain intact, thereby creating room for more mistakes in the future.
In 1997, the RCA methodology for healthcare settings was developed with this system-orientation at its core. The focus shifted from pointing out failure of responsibilities of individuals to finding underlying causes and to prevent the occurrence of adverse events through taking system-oriented corrective actions. The “whats” and “whys” of an adverse need to be investigated, but it is even more important to explore the “whys” — the root causes. The primary goal of the RCA methodology is to gain a systems-level understanding of the adverse event.
The RCA methodology intends to promote learning rather than to simply pin down the blame and punish the individuals involved. In general, RCA methods are applied in a wide variety of industrial settings to identify root causes of problems or adverse events. Used in any setting, the basic philosophy of RCA practice is to find and address the root causes as opposed to addressing merely symptoms or manifestations. Also, since correction cannot usually happen by a single intervention, the RCA process is normally iterative. The dynamic of continuous improvement is implicit in RCA methodology.
Furthermore, since systems in the healthcare framework tend to be closely interlinked at the root cause level, the general emphasis is on continuous overall improvement of the systems and processes in an organization. RCA helps us to prioritize the changes required, and recommends how best to go about implementing the necessary changes. As listed in the JCAHO manual, “Root Cause Analysis in Healthcare: Tools and Techniques,” there are 4 components and 21 steps to the RCA process (Joint Commission Resources, iii). These are: I. Preparing for root cause analysis One: Organize a team
Two: Define the problem Three: Study the problem II. Determining what happened and why: the search for proximate causes Four: Determine what happened Five: Identify contributing process factors Six: Identify other contributing factors Seven: Measure / Collect and assess data on proximate and underlying causes Eight: Design and implement interim changes III. Identifying root causes Nine: Identify which systems are involved — the root causes Ten: Prune the list of root causes Eleven: Confirm root causes and consider their interrelationships IV. Designing and implementing an action plan for improvement
Twelve: Explore and identify risk reductions strategies Thirteen: Formulate improvement actions Fourteen: Evaluate proposed improvement actions Fifteen: Design improvements Sixteen: Ensure acceptability of the action plan Seventeen: Implement the improvement plan Eighteen: Develop measure of effectiveness and ensure their success Nineteen: Evaluate implementation of improvement efforts Twenty: Take necessary additional action Twenty-one: Communicate the results As we can see, the corrective process is embedded into the RCA process and forms its fourth component.
In another slightly different version the RCA process is divided into five components, which are as follows (Joint Commission International, 35): • Delineation of the specific sequence of events leading up to the event and the identification / involvement of the specific departments, services or personnel. • Identification of the proximate causes of the event • Explanation of “why” and “if” errors occurred and what systems contributed to the vulnerability. • Identification of the action needed, including system/process improvements to prevent another such event.
• After corrective action plans and risk reduction strategies are implemented, data will be collected to ensure the effectiveness of the action plan as appropriate. An RCA is a response to adverse event, looking at what happened, what proximate causes were behind it, and what systems or processes — the root causes — explain the proximate factors. Root causes are the most fundamental causal factors of an adverse event which can be addressed by a healthcare organization. There would be further causes even for these root causes, but they lie outside the purview of the hospital.
A healthcare facility should be more concerned about what it can do in practical terms rather than delve deeper and deeper into the causes of a problem in a philosophical sense. The RCA process is all about digging deeper but there comes a point when further causal linking, even though it is possible, would be of no practical relevance. The RCA process must restrict itself to the realm of practicability. Usually, an RCA goes up to four or five levels of asking ‘why’ before it could come up an effective remedial strategy.
The RCA group must above all avoid the mistake of taking proximate causes for root causes. The group should beware of the tendency to stop the process of investigation too soon and decide upon an action plan before the root causes are completely identified. Treating the symptoms rather than causes would have some beneficial effects, but it cannot guarantee that the critical process variation that caused an adverse event would not recur. 7. RCA terminology Some of the terms associated with the RCA process can serve to better illuminate what it is all about.
Action Plan: It is the outcome of a root cause analysis and contains a proposal for corrective measures. The goal of both RCA and the action plan is to find ways to prevent repeated occurrence of adverse events and close calls (AHRQ). Adverse Events: Untoward incidents, iatrogenic injuries or other adverse occurrences happening within the premises of a healthcare organization Adverse Drug Events: ADEs are adverse events specifically associated with medication and other therapeutic agents. Anchoring Error (or Bias): A cognitive tendency to err by letting first impressions predominate diagnostic judgment.
Benchmark: In healthcare setting, it means an attribute or achievement that serves as a standard for other hospitals to emulate. Checklist: Flowchart-type listing of actions to be performed in a particular clinical setting to ensure that all the steps are performed in order. Close Calls: A close call is a near miss, a potential event. They can present great opportunities for learning. Competency: The possessing of requisite knowledge and technical skills to perform a particular procedure with a success rate that can be considered acceptable.
Computerized Physician Order Entry or Computerized Provider Order Entry (CPOE) : A computer-based system of ordering medications and diagnostic tests. Confirmation Bias: The tendency to take the evidence that supports a working hypothesis for granted, without being concerned to look for evidence that could provide support for an alternative hypothesis Contributing Factors: Additional reasons surrounding the basic reasons. Decision Support: Any kind of system that can provide advice or guidance about a particular clinical decision.
Heuristic: Rules of thumb; informal rules normally arrived at through experience. Human Centered Design and Usability: User-friendly design which enhances human performance. Human-centered devices are intuitive and easy to use. Human Factors (or Human Factors Engineering): The role human abilities and characteristics play in the operation of equipment and systems. Intentional Unsafe Acts: Seeming medical errors which happened from an intention to harm. Safety Assessment Code Matrix: The SAC matrix is a simple to determine the severity of an incident and probability of its occurrence.
Events are categorized as catastrophic, major, moderate, and minor; the probabilities of their incidence is categorized as frequent, occasional, uncommon, remote. Latent errors: Less apparent defects in organization or design that could contribute to the occurrence of errors. Production Pressure: The pressure to deliver a quantity of output, either of a product or service, even at the expense of safety. Red Rules: Rules that must be strictly followed. Situational Awareness: The quality of perception of a situation and the degree to which it can match reality
Triggers: Indications that can help detect likely adverse events. Triggering and Triage Questions: They are used to identify contributing factors in the aftermath of a sentinel event. 8. High-risk populations Emergency departments are high-risk environments for delivering medical care for patients. The multiple challenges physicians and nurses in EDs confront on a regular basis increase the risk of medical errors. In a 2000 study, Thomson et al. found the ED to be the one department in a hospital where there is the highest proportion of medical errors.
Patients admitted in EDs become a high-risk population for several reasons. Emergency departments generally tend to be noisy and crowded places that can even appear chaotic sometimes. There are frequent workflow interruptions. The sheer volume of patients in the EDs creates situations that present ample scope for error. Added to that, ED patients do not arrive on scheduled timings. Also, ED volumes keep fluctuating, which makes it difficult to make the staffing adjustments according to the swings in demand.
Another reason for ED patients being at higher risk than normal is that ED personnel routinely work under a great deal of stress. They are required to see all kinds of patients and make rapid decisions in a very short time-frame, and that too without sufficient patient information. While physicians normally see one patient at a time, as in the operation theater or during clinical consultations, ED physicians are often burdened with the care of 10, 20 or more patients at a time, these patients generally manifesting acute symptoms from accidents and a variety of maladies.
The frequency of errors in the EDs tends to increase during the night shifts (Crosskerry et al, 44). Prescription and medication errors also tend to occur more in the EDs than in any other department of a hospital. A 2005 study of medication errors among the acutely ill and injured children in several rural hospitals found out that a shocking 48 percent of patient charts were in error. In general, more acutely ill patients are likely to be victims of medical error than those suffering from less serious illnesses or injuries.
That is the reason ICU’s have become the focus of many initiatives to reduce medical errors in our hospitals, as we shall see in the following section. The IOM has identified six requirements of quality health care: • safety • effectiveness • efficiency • timeliness • patient-centered treatment • equitability If patients are to receive optimal care these interdependent requirements have to be poised in a balance with no single characteristic being given a special preference over the other. In the context of emergency department settings, timeliness generally tends to dominate the other requirements.
While this is understandable, in the best interests of their patients ED personnel have to focus on delivering quality care by equally emphasizing all the six requirements. Patient safety and efficiency have to be reconciled in a dynamic balance. EDs are also the crossroads of a hospital. Ensuring safe transitions and transfers requires coordinated processes, structured information and clearer definitions of roles and responsibilities for staff in both initiating and receiving departments. There is a particular need for the hospital leadership to develop a systems view of process flows in the ED setting and strive to improve them.