Key questions for your investigation
If you are doing a root-cause analysis (RCA) of an adverse patient care event, there are seven questions your investigation team needs answered. (For a detailed description of how to perform an RCA, see related story, p. 137.) They are:
1. Has this happened before? The answer to this question gives vital information regarding the nature of the problem and the efficacy of any previous corrective or preventive actions taken.
2. What was done to fix it? If there was a problem before and nothing was done, it's time to do something. If previous solutions didn't work, you must redesign corrective actions.
3. What was different this time? Sentinel events are rare occurrences. The investigation team needs to find out what differed this time. Compare a flowchart of what usually happens with what happened this time to identify differences.
4. Did people do what they were supposed to do? The answer might be hard to obtain if the organizational climate is not supportive. But it can point to problems in systems, training, or performance appraisals. It is important to keep the investigation team focused on the performance of the system, not just how individuals performed.
5. Did people know what to do? The answer to this question can point out holes in present systems that prevent people from knowing what to do. Staff can't be trained for every possible situation, but the team can determine what critical thinking skills were lacking and how they can be reinforced through coaching or education.
6. Who reported this event? This gives clues to problems with the reporting system itself. Was the person who reported the event the one who should have noticed it first? If not, talk with the person who ought to have reported it and find out why he or she didn't see it. The goal of this is not to place blame, but to find and resolve underlying system issues that need correcting.
7. Did any event or action prevent an even worse situation? Answering this question helps the investigating team think through solutions to the problem and identify current problems in procedures and training.
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