Judge effectiveness with actual data, observations
As a part of their overall patient safety program, many health care organizations require that managers submit corrective action reports for every significant incident in their department. Those corrective action reports may give senior leaders the feeling they are doing something about every identified problem. However, such reports may represent more of an illusion of patient safety rather than reality.
In some cases, when an incident reveals an obvious equipment problem that can be remedied through repairs, such corrective actions may genuinely contribute to improved patient safety. In other incidents, there may either be no obvious fix that would eliminate the problem that was observed in the incident, or the needed changes may simply be too expensive to implement.
In those instances, the requirement to identify a corrective action for each incident tends to result in corrective action reports that are long on promises — such as reducing staff distractions or implementing better maintenance procedures. Such “mother-and-apple-pie” pledges of corrective action do not ensure a reduced risk to patients.
Action plans such as those often are hard to enforce, and broken promises may become evident only when similar types of incidents reoccur. Corrective actions that involve staff counseling or training are equally problematic. Even if the promised counseling is done, it is unclear whether this intervention actually will reduce the risk of similar incidents.
When the corrective action report simply says that the particular employee involved in the incident was “counseled,” it presumably means the employee was instructed not to make the same mistake in the future. Another similar example of a motherhood-and-apple-pie corrective action is staff training. If the person involved in the incident is particularly ill trained, then retraining actually might be helpful. However, most likely, future instances of the same type of error will not involve the same employee.
Finding the root cause
If the problem is important, it should be brought to the attention of all staff members who could potentially end up in similar situations, not just the particular person involved in the most recent incident. Without doing a definitive root-cause analysis for each incident, it often is difficult to determine whether the promised corrective action is even relevant to the problem at hand. For example, a frequent type of human error is failure to use equipment properly, e.g., not programming an IV pump correctly. If this is done purely as a result of inattention, then counseling employees to pay closer attention could conceivably be effective.
However, if the instructions are vague or if the equipment is used only occasionally, it is unclear whether most employees would be able to reliably use the equipment properly. In this situation, providing better labeling and easily accessible instructions are likely to be much more effective than counseling the employees to pay closer attention to their work.
Even when a definitive root-cause analysis is done, this also can give the illusion of patient safety instead of the reality if the root causes are not actually found and corrected.
Incident investigation teams often stop their analysis before the root causes are uncovered. Thus, actions are directed at the significant contributing causes, not the root causes. Take for example incidents involving misadministration of medications in the operating room.
The apparent root cause of many of those events is the lack of an identifying label on the containers used to store drugs on a sterile field (syringes, basins, or other vessels).
The corrective action: All containers must be labeled with the name of the medication in the container. So, why do hospitals continue to have similar types of medication errors in the operating room if the root cause has been accurately identified and the proper corrective action implemented?
The most likely reason for continued problems is that the underlying latent system failures have not been found and corrected. In a 2004 survey of approximately 1,600 hospitals by the Huntingdon Valley, PA-based Institute of Safe Medication Practices, more than 42% reported inconsistencies in their labeling of medications and solutions on the sterile field.1 It is the latent system failures that allow for these inconsistencies, not the lack of a defined procedure. For example, is there inadequate supervision? Are staff members not held accountable for complying with procedures? Are there insufficient resources (e.g., not enough labels)? Do senior leaders have a laissez-faire attitude toward patient safety? Is there a culture of complacency? Will the same problem reoccur?
Those are the types of latent system failures that often are overlooked during a root-cause analysis. Yet these failures must be identified and addressed; otherwise, they will trigger more patient incidents of all types.
If an incident investigation stops when contributing causes have been identified, the underlying system problems are never addressed. To get to the root-cause level, the investigation team must ask, “Why was this situation allowed to exist?” Answers to this question will help uncover the latent system failures that represent the true root causes.
The purpose of this example is not to argue that root-cause analysis is undesirable or counterproductive, but simply to point out that the act of performing a root-cause analysis does not ensure that the root causes actually are found. Leaders can observe that the investigation did indeed take place, but the effectiveness of the root-cause analysis only can be judged in retrospect by the absence of similar incidents in the future.
The existence of a root-cause analysis creates an illusion of patient safety; only the absence of future events confirms the reality of safety.
It may well be appropriate to require a root-cause analysis for each significant patient incident that occurs just to ensure such events are treated with appropriate seriousness. However, resources may be wasted if there is pressure to find a so-called “root cause” in each incident investigation and implement a corrective action for each identified root cause. More importantly, this may contribute to the illusion of safety by creating a pretense that the root cause of every significant incident has been found and fixed.
Organizational initiatives intended to ensure patient safety are beneficial in many instances. The intent is not to discourage root-cause analyses, corrective actions, and other worthwhile processes changes, but rather to point out that the goal of maximizing patient safety is very elusive.
Requiring incident investigations and corrective action reports can give management the false security that something is being done about all identified problems. However, if only contributing causes are being identified or if corrective actions are mostly motherhood-and-apple-pie interventions, the impression of patient safety may in fact be deceptive. To keep from being fooled by this illusion, organizations must judge the effectiveness of patient safety programs and improvements based on actual data and observations, not solely on the number of incident investigations completed or corrective actions implemented.
Reference
1. Institute for Safe Medication Practices. ISMP Medication Safety Alert. Dec. 2, 2004.
As a part of their overall patient safety program, many health care organizations require that managers submit corrective action reports for every significant incident in their department.
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