Adverse outcome leads to test of root cause analysis
One hospital's experience with investigating an adverse incident suggests the guide for conducting a root cause analysis is less useful than a carefully organized discussion of the incident by all involved parties.
Provided by the Joint Commission on the Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, the root cause analysis is intended to help health care provides learn the true, systemic cause of adverse events, rather than pointing fingers at the individuals who made the errors. But when an adverse event occurred at a hospital in the Valley Health System in California, district risk manager Rosemary Gulizia, RN, JD, found the analysis was only a starting point.
She and her colleagues initially used it to investigate the incident, but they found themselves veering toward a format that better suited their needs. The incident occurred recently in the emergency room of one of her system's hospitals when a patient's condition worsened after a physician gave orders for his care. (For confidentiality and liability reasons, Gulizia is unable to describe the adverse event in more detail.) The event was serious enough that it might be considered a sentinel event, so Gulizia wanted to ensure the investigation was handled in a thorough way. She provides Healthcare Risk Management with this description of what she did and learned:
o Reacting initially to the event.
"When the message came in that a hospital in our system experienced an adverse outcome, one of my first thoughts was, `Oh no, now we might have to figure out how to do the root cause analysis.' As it turned out, the adverse even was just that, a poor outcome. After our careful analysis, we agreed that the event was not sentinel."
However, Gulizia learned the root cause process could be used as a problem-solving measure for any situation in which a hospital is committed to improving its systems. She and her colleagues decided to use the root cause analysis to investigate the adverse outcome. The process is the same whether or not the event in question was sentinel.
The first steps were to inform the appropriate people and identify the key personnel involved in the event. At this stage, the key persons decided it was necessary to hold a formal meeting.
o Organizing the group.
A designated person coordinated the meeting time and dates, no easy task because many people and schedules were involved. Fifteen people were selected to attend, including the chief of staff, administrator, risk manager, quality improvement coordinator, and the physicians and nurses who were involved in the patient's care. The administrator's presence was important because it indicated the hospital took the process seriously.
o Setting the time.
It was decided that the best time for the meeting would be after normal business hours. That would minimize disruptions and make it easier for the physicians to attend. The physicians and nurses arranged for coverage during the meeting.
o Recording the meeting.
Two people were delegated the task of taking notes. Later, those notes were merged into one report, which helped sort out the multiple issues and complex subjects to be discussed.
o Choosing the setting.
A comfortable room in the hospital was chosen for the meeting, and dinner was served. The administrator felt it was important to make all the attendees comfortable so they could focus on the issue at hand. The meal eliminated the urge to end the meeting prematurely due to hunger or dinner plans.
o Establishing confidentiality.
The chief of staff chaired the meeting. He started by outlining the ground rules:
1. Everyone will have a chance to speak.
2. The meeting is a function of the medical staff peer review/quality improvement committee. Accordingly, all pertinent rules apply.
3. The contents of the meeting were not to be discussed outside the room. No exceptions.
4. Everyone can discuss what happened without fear of reprisal.
The chairman spent some time explaining to those who had never been involved in this sort of process the state laws governing peer review and quality improvement activities. The intent was to help them understand the confidential nature of the meeting.
o Collecting signatures.
Each person at the meeting was required to sign a document containing this statement:
Confidentiality statement - In accordance with the Medical Staff Bylaws, all records and proceedings of all medical staff meetings shall be considered confidential. Effective peer review and consideration of qualifications of medical staff members and applicants to perform specific procedures must be based on free and candid discussions. Any breech of confidentiality will be deemed disruptive to the operations of the hospital and medical staff.
For the purposes of such a meeting, the statement might be improved by adding a sentence that includes ancillary persons other than medical staff. The document also could include the statement that no discussions of the meeting's contents are to take place outside the meeting.
o Discussing the event.
JCAHO's root cause analysis was used initially to guide the meeting, but the participants found they wanted to discuss the event in ways that didn't fit into the root cause format. After a while, the meeting participants decided to abandon the root cause analysis and discuss the event more freely.
Because of the multiple issues and complex situations, the participants decided to draw a time line to keep track of the sequence of events. This visualization clarified the discussion and eliminated unnecessary repetition of the facts.
o Reaching conclusions.
The meeting lasted 31¼2 hours. At first, there was some hesitance in discussing the roles everyone played. The participants found it was unrealistic to expect that only processes would be discussed and not people. After all, people set the wheels in motion for the event to occur. That realization was a major reason the meeting participants decided to abandon the root cause analysis.
Even so, the meeting didn't dissolve into a finger-pointing session. Group members stepped in at times to remind everyone that the point of the meeting was not to blame individuals but to outline exactly what happened so the underlying cause and appropriate remedy could be identified.
The participants identified some weaknesses in the hospital's systems, but ultimately they concluded the patient's outcome had nothing to do with those weaknesses. The meeting, however, proved to be an important trial of the root cause analysis and yielded information about the investigatory process that will be used the next time the hospital must address an adverse outcome.
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