Do your root cause analyses fail to improve safety? Take these steps
Process often involves wrong people
Finding someone — usually a nurse — to blame without looking at the underlying reasons an error was made. Failing to involve hospital leaders in fixing serious systemic problems. Changing a policy or educating staff without addressing necessary process changes.
These are three common problems with root cause analyses (RCAs), which are required by The Joint Commission for every sentinel event that occurs at your organization. Unfortunately, the process often fails to answer the most important question: Has the risk of recurrence actually been reduced?
There isn't always a consistent, timely, and standardized process for RCAs, says Bev Cunningham, MS, RN, vice president of clinical performance improvement at Medical City Dallas Hospital. When an RCA is done, the following must occur, she says:
- The director of the involved area, and any involved physicians, must participate.
- There must be a timely discussion and analysis, and assumptions must not be made. "Too many times, we make assumptions that we know what happened. The analysis should be done without assumptions," says Cunningham. "If the hospital has a management engineer who is not clinical, it's a great opportunity to involve this person, as they will ask questions without assumptions."
- Upon implementing the action plan, education must be given — not only to staff in the affected department, but also to other relevant staff.
If audits show that the measures of success you've implemented are successful, this best practice should then be shared throughout the organization, says Cunningham. For example, changes in the OR should also be included in any other area where surgical-type procedures are done, such as labor and delivery, the cardiac catheterization lab, gastrointestinal laboratory or radiology special procedures.
Action plan items must be tested for areas that could break down, resulting in a failure of the RCA. "The action plan that is decided by a group of people might sound good, but it may not be the best one," says Cunningham. "This is where research and best practice from the literature comes in. However, best practice in the literature may not always be the right action plan for a particular facility."
After the RCA and action plan are completed at Medical City, a meeting is held with the appropriate hospital executive team members, to be sure that additional options are not being missed. "In larger facilities, it's important for the executive team to be involved. This places accountability in the correct place," says Cunningham. "We found that in our 660-bed hospital, this group is integral to a successful RCA."
Staff training is key
"I find RCA to be one of the most valuable and effective tools in the quality toolbox," says Claire Davis, vice president of quality at Norwalk (CT) Hospital. "The methodology is extremely sensitive and specific, allowing users to identify process failure modes in detail, and, therefore, target action plans most guaranteed to eradicate the root."
Unfortunately, RCAs may be ineffective for a number of reasons — most due to "user failures," says Davis. "It is essential that the tool be applied by competent, well-trained quality professional leaders and facilitators. RCA is not a tool for beginners or untrained personnel."
For a "scientific RCA approach to studying errors," Davis recommends taking these four steps:
- involve trained and competent staff;
- invite the correct people to the table;
- use a "no-blame" approach;
- develop action plans.
If these steps are followed, then the effectiveness of RCAs "will become quite evident," says Davis.
"I have also found that as we have gotten better in our quality department at running excellent RCAs, the physicians and other clinical staff are now calling us with increased frequency because they have found the tool so valuable," says Davis.
A recent RCA involved a case of a pressure ulcer at the site of a continuous positive airway pressure (CPAP) mask on an intensive care unit patient. One of the root causes identified was that although nurses "own" assessment and intervention with skin integrity, CPAP masks were only removed and reapplied by respiratory therapy staff due to the need for a proper fit for adequate oxygenation.
Consequently, nurses were not examining the skin under the mask. Therapists were focused on ensuring oxygenation, not assessing skin integrity. One of the actions taken as a result of the RCA was creation of a procedure and policy in which the mask changes are done by a team consisting of the patient's nurse and respiratory therapist. The nurse is there to assess skin and communicate interventions for any integrity issues with the physician.
"The nurse and respiratory therapist then approach the intervention plan as a physician-directed team," says Davis. "This is a typical example of how a simple systems problem has a simple fix."
Davis says that individuals administering an RCA should preferably be CPHQs, and should have additional training on the use of RCA. "There are many one-day seminars available on RCA that staff can attend for this training," she says.
At Norwalk, newer staff are first required to observe a number of RCAs done by more experienced staff. Next, they participate in several RCAs under observation, before being deemed competent for a lead RCA assignment of their own.
Davis also recommends that two quality professionals perform each RCA, being careful to maintain strong roles — one as a leader of the process, and one as a facilitator. The leader keeps the agenda and meetings moving along, while the facilitator addresses power struggles to make sure that no one person is "hijacking" the review.
"They remind everyone that this is not about blame, and assist the leader in getting to the facts of the case without emotion and in a data-driven fashion," says Davis.
RCAs often engender strong emotional reactions in participants. "Those involved in an error, particularly one that has harmed or caused death, are obviously upset, saddened, or angry with themselves and with each other at times," says Davis.
There is a tendency to blame oneself or others, depending on the situation. This can get in the way of factually and objectively finding and analyzing facts. "This is mitigated, but never entirely avoided, by a good facilitator who shows that we are looking at this case in a no-blame, systems approach fashion," says Davis.
For example, the facilitator might start out by saying to participants: "I know that nobody comes to work to make a mistake. In fact, I am sure this is devastating to you."
The facilitator may need to continue to reinforce this point, since participants are likely to revert back to a subjective, emotional reaction if things get heated. "Many hospitals offer debriefing and counseling for staff, and this is great. But that should occur in a forum other than a root cause meeting," says Davis.
Study IDs common problems
In Maryland, patient safety experts at the state department of health review RCAs submitted by hospitals in response to serious events. "Our concerns about the quality and depth of RCAs is not just a matter of regulatory and technical compliance," says Wendy Kronmiller, director of the Office of Health Care Quality. "We believe that hospitals which take the time and effort to look seriously at systems problems after a patient is harmed will be far more likely to identify real corrections so that the event is less likely to reoccur."
Last year, almost half of the RCAs reviewed were found to be problematic in at least one area, according to the Maryland Patient Safety Report for 2007.
Here are some of the problems that were found with RCAs done in 2007:
• Lack of involvement of hospital leadership. "It is almost impossible to identify and resolve systemic problems without involvement and support at the management and director level," says Kronmiller.
• Concluding that a single individual is responsible for the adverse event rather than investigating further to identify deficient processes and systems.
Blaming an individual is often the easiest thing to do, and has been a typical reaction at organizations for many years, says Kronmiller. "It is occasionally frustrating for my staff when they do see RCAs focusing on firing staff or re-training staff as the primary response," she says. "It typically means that the organization does not get the importance of looking for the true systems problems underlying an individual's error. And to us, that means that the error will likely reoccur."
Occasionally, the patient is blamed. After a failed procedure to remove a gallbladder of an elderly and confused patient whose gallbladder had in fact been removed 20 years previously, the root cause identified was the patient's lack of knowledge regarding the previous surgery.
This RCA illustrates an attempt at "paper compliance" — going through the regulatory motions without real acknowledgement of the value at looking for the true sources of problems. "Certainly this was not the first time a patient was a poor historian, and it likely will not be the last," says Kronmiller. "While this is an extreme example, it illustrates an RCA which will not prevent the exact same poor result."
• Failure to develop an appropriate corrective action plan to address the root cause(s).
"Hospitals continue to focus on re-training and re-educating individuals who are usually already highly educated and trained and who make errors nonetheless," says Kronmiller. "We believe hospitals should look to stronger responses, such as workload and environmental changes and equipment modifications."
[For more information, contact:
Bev Cunningham, MS, RN, Vice President Clinical Performance Improvement, Medical City Dallas Hospital, 7777 Forest Lane, Dallas, TX 75230. Phone: (972) 566-6824. Fax: (972) 566-7533. E-mail: [email protected].
Claire Davis, Vice President, Quality, Norwalk Hospital, 34 Maple Street, Norwalk, CT 06856. Phone: (203) 852-2212. Fax: (203) 852-3436. E-mail: [email protected].
Wendy Kronmiller, Director, Office of Health Care Quality, Maryland Department of Health, 55 Wade Avenue, Catonsville, MD 21228. Phone: (410) 402-8015. E-mail: [email protected].]
Finding someone usually a nurse to blame without looking at the underlying reasons an error was made. Failing to involve hospital leaders in fixing serious systemic problems. Changing a policy or educating staff without addressing necessary process changes.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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