Uncover root causes with E&CF charts
Illustrate causal factors in accident sequence
By Patrice Spath, RHIT
Brown-Spath Associates
Forest Grove, OR
Sentinel events must be investigated to identify the causes of their occurrence and to determine what must be done to prevent recurrence. It is essential that caregivers probe deeply into both the events and the conditions that created the undesirable situation and the underlying system issues that allowed the conditions to exist. Through this investigation, the health care team will identify the root causes of the sentinel event. Identification of root causes requires a systematic analysis of the interaction of events and causal factors.
Experience has shown that significant patient incidents almost never result from a single cause. They are usually multifactorial and develop from clearly defined sequences of events that involve performance errors, changes, oversights, and omissions. The team of caregivers charged with investigating patient incidents needs to identify and document not only the events themselves but also the relevant conditions affecting each event in the sequence. To accomplish this, the team must rigorously examine the steps leading up to the undesirable outcome.
The emphasis of the sentinel event investigation should be placed on discovering all cause-effect relationships from which practical corrective actions can be derived to improve total performance. By itself, a flowchart may be an inadequate tool for this purpose. In private industry, an Events and Causal Factor (E&CF) chart is routinely used to discover the cause-oriented explanations of accidents. The E&CF chart combines flowcharting with cause-and-effect diagrams to reveal all causal factors through the sequence of events leading up to the undesirable outcome. An E&CF chart helps illustrate the multiple causal factors involved in the accident sequence, as well as the relationship of proximate, remote, direct, and contributory causes. By visually portraying the interactions and relationships of all involved processes and individuals, sentinel event investigation teams can link specific elements of the sentinel event to organizational and management control factors. An E&CF chart can assist in the verification of causal chains and event sequences, provide a structure for integrating investigation findings, and communicate investigation activities during and on completion of the project.
Construction of an event line of the actions leading up to the incident should begin as soon as possible. As soon as the risk manager or quality director starts to accumulate information on events and conditions related to the sentinel event, begin building a "working" event line of what happened. It is usually easiest to use the incident as the starting point and then reconstruct the pre-event and post-event sequences from that vantage point. The principal investigator should gather factual evidence pertinent to the accident sequence and begin to construct a picture of the occurrence. It is often helpful to rough out a list of possible causes of the occurrence. This can prevent false starts and "wild goose chases" but must be done with caution so you don’t lock yourself into a preconceived model of the accident occurrence or its causes.
The investigation team expands the E&CF chart as it gathers more information about the sequence of events. The team will identify missing parts of the sequence and investigate what happened during those parts of the sequence. This may result in several parallel sequences of event chains. Each chain may be unrelated to the other until one or more steps prior to the incident, where they come together to form one sequence of events leading up to the incident.
Information about the steps leading up to the incident usually will not be discovered in the sequential order in which they occurred. Initially, there will be many holes and deficiencies in the event line. Efforts by the investigation team to fill these holes and get an accurate account of the event sequences and the conditions that contributed to the medical accident will lead to deeper probing to uncover the true facts involved.
Once the investigation team clearly understands the sequence of events, it can begin to identify the conditions that created the undesirable situation. This is done by answering "why" questions about each event. Through this questioning process, the team identifies the causal factors — the situations or circumstances that existed at the time of the event that contributed to the occurrence of the incident. These may be negative or positive causal factors that describe circumstances or states as opposed to occurrences or happenings. Eventually, the team will be asked to identify the root causes of the sentinel event. This requires an understanding of the interaction of events and causal factors through a chronological chain of activities. To the extent possible, all direct and contributing causal factors should be identified.
A simple E&CF chart for an undesirable incident accompanies this article. (See E&CF chart, above.) In real life, the event line would be more detailed and more causal factors would be identified. This illustration shows the basic structure of an E&CF chart.
Once the team is satisfied that it’s identified all the causal factors related to each event leading up to the incident, the team begins to dig deeper to find the root causes. By asking more "why" questions for the causal factor, the root causes can be discovered. For instance, in the incident described in the E&CF chart above, the physician failed to identify the warning signs of an impending subdural hematoma. This factor is not the root cause. The team must dig deeper to identify the underlying problem by asking, "Why did the physician fail to recognize the early warning signs?" After studying the issue in detail, the answer to this question might be: "The physician is inexperienced in head trauma cases." This is a root cause that needs to be eliminated to prevent future incidents of this type. This questioning is continued several times for each of the causal factors until the team agrees it’s identified root causes.
The primary purpose of a sentinel event investigation is to determine what happened and why it happened in order to prevent similar occurrences and to improve the safety and efficiency of future patient care operations. When serious events occur, they are often symptomatic of systemic deficiencies that impair performance in all areas. The E&CF chart is a useful root-cause analysis tool that can be used by the investigation team to determine the underlying causes of sentinel events so incident-producing errors can be reduced and controlled.
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