Patient Safety Primer. Root cause analysis RCA is a structured method used to analyze serious adverse events. Initially developed to analyze industrial accidents, RCA is now widely deployed as an error analysis tool in health care. A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals. RCA thus uses the systems approach to identify both active errors errors occurring at the point of interface between humans and a complex system and latent errors the hidden problems within health care systems that contribute to adverse events.

It is one of the most widely used retrospective methods for detecting safety hazards. A multidisciplinary team should then analyze the sequence of events leading to the error, with the goals of identifying how the event occurred through identification of active errors and why the event occurred through systematic identification and analysis of latent errors Table.

The ultimate goal of RCA, of course, is to prevent future harm by eliminating the latent errors that so often underlie adverse events. A patient on anticoagulants received an intramuscular pneumococcal vaccinationresulting in a hematoma and prolonged hospitalization. The hospital was under regulatory pressure to improve its pneumococcal vaccination rates. Lacking the appropriate equipment to perform hysteroscopy, operating room staff improvised using equipment from other sets.

During the procedure, the patient suffered an air embolism. A surgeon completed an operation despite being informed by a nurse and the anesthesiologist that the suction catheter tip was missing. The tip was subsequently found inside the patient, requiring reoperation. An overworked nurse mistakenly administered insulin instead of an antinausea medication, resulting in hypoglycemic coma. The patient experienced an opiate overdose and aspiration pneumonia, resulting in a prolonged ICU course.

A traditional analysis might have focused on assigning individual blame, perhaps to the nurse who sent the patient for the procedure despite the lack of a consent form. However, the subsequent RCA revealed 17 distinct errors ranging from organizational factors the cardiology department used a homegrown, error-prone scheduling system that identified patients by name rather than by medical record number to work environment factors a neurosurgery resident who suspected the mistake did not challenge the cardiologists because the procedure was at a technically delicate juncture.

This led the hospital to implement a series of systematic changes to reduce the likelihood of a similar error in the future. RCA is a widely used term, but many find it misleading. Labeling one or even several of these factors as "causes" may place undue emphasis on specific "holes in the cheese" and obscure the overall relationships between different layers and other aspects of system design.

Accordingly, some have suggested replacing the term "root cause analysis" with "systems analysis. Root cause analysis is one of the most widely used approaches to improving patient safety, but its effectiveness has been called into question. Studies have shown that RCAs often fail to result in the implementation of sustainable systems-level solutions.

A commentary identified eight common reasons for ineffectiveness of the RCA process, including overreliance on weak solutions such as educational interventions and enforcing existing policiesfailure to aggregate data across institutions, and failure to incorporate principles of human factors engineering and safety science into error analysis and improvement efforts. The National Patient Safety Foundation has proposed renaming the process root cause analysis and action RCA2 —emphasizing that a well-done RCA should yield robust corrective actions and risk reduction.

As detailed in a Annual Perspectivesafety experts agree that effective error analysis requires the active involvement of organizational leadership, training of specialized teams with expertise in safety science, focusing on stronger systems-level solutions, and measuring implementation and impact on outcomes. Given the considerable time investment required to perform a formal RCA, more abbreviated incident analysis techniques may be appropriate in some cases. The Joint Commission has mandated use of RCA to analyze sentinel events such as wrong-site surgery since As of25 states and the District of Columbia have mandated reporting of serious adverse events increasingly using the National Quality Forum's list of " Never Events "and many states also require that RCA be performed and reported after any serious event.

Although no data are yet available on this subject, RCA use has likely increased with the growth in mandatory reporting systems. Last Updated: September Root Cause Analysis. Approach to Improving Safety.

Resource Type. Patient Safety Primers. Content Areas. Facebook Twitter Linkedin Email.Word Version [ - Background: A standardized approach to postfall evaluation is key to maintaining the patient's safety and for organizational learning about how to prevent future falls. Reference: This tool is adapted from a tool developed by Ronald I.

Shorr, MD, M. Improving the capture of fall events in hospitals: combining a service for evaluating inpatient falls with an incident report system. Clarifying confusion.

Ann Intern Med ; 12 How to use this tool: The information below can be customized for use within your hospital. Note that the tool was originally used as part of a dedicated fall evaluation service that was called to investigate each fall. For details, see the Shorr reference. This tool can be used by staff nurses and information systems staff.

The tool may be used for the purpose of root cause analysis to prevent future falls in this patient and in future patients. This assessment should be performed in conjunction with a medical provider's or pharmacist's assessment of medications contributing to fall risk go to Tool 3I, "Medication Fall Risk Score and Evaluation Tools" and a medical provider's assessment of laboratory test results, if appropriate.

A separate tool Tool 3N, Postfall Assessment, Clinical Review covers how to assess and follow injury risk immediately after a patient has fallen. One less error is allowed if the patient has had education beyond the high school level. Section 2. J Am Geriatr Soc ;23 10 Pfeiffer, Used with permission, Sharon K.

VA National Center for Patient Safety

All rights reserved. Please record orthostatic blood pressure readings in the patient's chart and return this form to the designated place in the staffing office.

Return to Roadmap. Content last reviewed January Browse Topics. Topics A-Z. Quality and Disparities Report Latest available findings on quality of and access to health care. Funding Opportunity Announcements. More topics in this section Programs. Previous Page. Next Page. Tools and Resources 6. How do you sustain an effective fall prevention program? How do you measure fall rates and fall prevention practices? How do you implement the fall prevention program in your organization?

Which fall prevention practices do you want to use?

HCD Case Study – 28 Case Studies related to Healthcare Process Improvement with Culture Changes

How will you manage change? Are you ready for this change? Icons Overview Acknowledgments References. Postfall Assessment 1.Techniques, such as Fishbone Diagram, 5 Whys, and. Pareto Analysis are commonly employed. As there are many articles on BrightHub and the Internet that elaborately describe the procedure for conducting a Root Cause Analysis, the focus of this article is to provide scenarios for Root Cause Analysis applicable to the following industries:.

Image credit: Rupen Sharma. As you might have already experienced, quality healthcare is dependent on the staff and the specialized equipment in a clinic or hospital. At a recent trip to the hospital, I noticed several scenarios that would be good candidates for conducting an RCA. Some of them are listed below:. In the healthcare world, time may or may not lead to financial losses, but. For example, imagine there was a case where a patient needed a physiotherapy session.

Here is a Root Cause Analysis in the healthcare industry that uses the 5 Whys approach for solving the identified problem:. From this scenario, I could easily conclude that by buying more trolleys, all patients would be brought to the physiotherapy session on time.

How To Conduct a Root Cause Analysis of a Critical Incident

But, would that really be true? There are other factors to consider before going out on a buying spree. Could it be that there is no maintenance plan in place!

If that is the case, then it is fair to assume that the problem will recur, even if you purchase more trolleys.

You could conduct a Fishbone to better understand the Cause-Effect of this scenario. Image credit: SXC. Mechanical failure leads to production loss and plant downtimeassuming there is no contingency plan in place. Each component in a. This could be because of poor component design or poor component material. As with most industries, your experience would help you determine some probable causes.

The most common causes for service failure or breakdown are incorrect operation, inadequate maintenance, bad workmanship, and incorrect repair that introduces new defects. These causes are for Scenarios 1 and 3. Scenario 2 is primarily related to safety procedure development and adherence. It may also require training. Image credit: SXC under licensing agreement.

root cause analysis case studies healthcare

Practically every organization that sells a product or offers a service has a customer service department. The consequences of poor customer services typically includes dissatisfied customers, lower sales, increased customer service costs and fewer customers that would buy the product or service again.Select an industry on the left to view its case studies on the right.

Each example has a downloadable PDF to accompany the write-up. In this case the devastation in New Orleans due to Hurricane Katrina is captured as an example of the Cause Mapping method. The three steps in the Cause Mapping method are 1 Define the problem, 2 Conduct the analysis and 3 Identify the best solutions… View Case Study Yarnell Hill Fire - 19 Firefighter fatalities This is an example of how the Cause Mapping process can be applied to a specific incident.

root cause analysis case studies healthcare

The three steps are 1 Define the problem, 2 Conduct the analysis and 3 Identify the best solutions… View Case Study Deepwater Horizon Oil Spill - Oil Spill lasts for months as solution after solution fails The Deepwater Horizon oil rig was in the final stages of exploratory drilling at the Macondo well in the Gulf of Mexico when disaster struck.

On April 20,the rig exploded, killing 11 workers and forcing the evacuation of the rig. This cautionary tale of unintended consequences has followed us since childhood. Though it is exaggerated and therefore funny—but really, how does one swallow a horse? The workers were unable to escape the fire. We can examine this incident using a Cause Map, a visual form of root cause analysis, which allows us to diagram the cause-and-effect relationships that led to organizational issues — in this case, the death of workers… View Case Study Buffalo Creek Flood of - Dam failure causes massive damage and deaths This is an example of how the Cause Mapping process can be applied to a specific incident.

Pet Food Contamination - Unsafe substitution of products We spend several billion dollars more on dog and cat food than on baby food. According to Bob Vetere, the president of the American Pet Products Manufacturers Association, 42 percent of pets sleep in the same bed as their owners — up from 34 percent in These statistics are startling to some and unsurprising to others. So you can imagine the uproar, panic, fear and anger it might cause when pets are endangered.

And you can imagine how pet owners must respond when their own pets are endangered… View Case Study. Guinea Worm Disease - Working to eradicate a painful parasite The lifecycle of the Guinea worm is the stuff of nightmares. This parasite is ingested by a host as larvae, mate and mature inside the host and then the adult female painfully emerges to lay her eggs. The adult female is between two to three feet long and the thickness of a spaghetti noodle.

More than 15 years later, this case is still presented by some as a case for legal reform to stop frivolous lawsuits and defended by others as an important victory for victims of powerful corporations.

root cause analysis case studies healthcare

But regardless of the legal implications, this famous case teaches a lesson about how to effectively solve problems… View Case Study Smoking - Why do people start? Why don't they quit? Most people who use them wish they could stop, nobody needs them, and nonetheless smokers will purchase their cigarettes with a loyalty and regularity that most other brands could only dream of cultivating in their customer base.

root cause analysis case studies healthcare

Put differently, one of five Americans per year die completely preventable deaths, 49, of which result from secondhand smoke exposure. Such statistics by far exceed what one might consider to be an acceptable level of risk for a completely optional and expendable activity… View Case Study.

Although the issues are still very much ongoing, it is possible to begin a root cause analysis of the events and issues. In order to clearly show one issue, our analysis within this blog is limited to the issues affecting Fukushima Daiichi Unit 3… View Case Study Deepwater Horizon Oil Spill - Oil spill lasts for months as solution after solution fails The Deepwater Horizon oil rig was in the final stages of exploratory drilling at the Macondo well in the Gulf of Mexico when disaster struck.

It quickly became clear that the emergency measures taken prior to evacuation had not sealed the well and that great amounts of oil were leaking into the Gulf of Mexico… View Case Study Dust Explosions - A root cause analysis primer How do you actually go about performing a root cause analysis?

This speech is for the purpose of updating the public on the investigation of the Imperial Sugar Company explosion and fire in Savannah, Georgia on February 17, at 1 p. In this case the explosion at the Formosa facility in Point Comfort, Texas is captured as an example of the Cause Mapping method.We use a multi-disciplinary team approach, known as Root Cause Analysis - RCA - to study health care-related adverse events and close calls.

The goal of the RCA process is to find out what happened, why it happened, and how to prevent it from happening again. Because our Culture of Safety is based on prevention, not punishment, RCA teams investigate how well patient care systems function.

We focus on the "how" and the "why"? Because people on the frontline are usually in the best position to identify issues and solutions, RCA teams at VA health care facilities formulate solutions, test, implement, and measure outcomes in order to improve patient safety.

The RCA process is a tool for identifying prevention strategies.

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It is a process that is part of the effort to build a culture of safety and move beyond the culture of blame. Close calls occur far more frequently than adverse events and can provide an exceptional opportunity for learning. The SAC Matrix is a tool for combining severity and probablilty. While either the severity or probability of occurrence could be determined first, it is usually more productive to assess the severity first.

A wide range of related information is available by scrolling through our Glossary of Patient Safety Terms. Veterans Crisis Line: Press 1. Complete Directory. If you are in crisis or having thoughts of suicide, visit VeteransCrisisLine. Quick Links.

Root Cause Analysis.Abstract: A not-for-profit healthcare system found that adherence to clinical quality observed metrics for inpatient heart failure discharge instruction was consistently below national standards. Working toward a goal of increasing the observed rate of compliance from Strategies developed to counter the vital Xs and improve the process included standardizing the discharge process across all nursing units, standardizing the most effective type of discharge instruction, improving the knowledge level of heart failure discharge instruction elements unit-by-unit with one-on-one training, and standardizing and simplifying the heart failure discharge instruction process.

The project was eventually expanded to address all forms of errors associated with surgical procedures. In the first year of Operation Takeoff, Tools used to understand the problem and evaluate improvements included brainstorming techniques, the 5 Whys, and a PICK chart.

This resulted in a reduction in gross days revenue outstanding by 2. The improvement team identified seven root causes as the vital few driving the extended stay time: congestive heart failure CHF standard orders not used, delay between discharge order to time patient leaves floor, patient stay included a weekend, patient becomes deconditioned because of lack of activity, practices were not based on Gold Standards, patients held after meeting InterQual discharge criteria, and inpatient holding process was not being standardized.

The baseline of stay continues to remain at an average of 3. Root cause analysis uncovered three primary reasons for non-compliance: takes too much time; dry, cracked hands from too much washing and use of soap; and a non-supportive culture. Solutions included making alcohol hand rubs and hospital-approved lotion more available, providing education and encouragement, establishing an infection control hotline to report non-compliance, and holding physicians accountable.

Principles of management science and operations research helped address the issue of capacity analysis and patient flow in the complex surgical facility. Discrete events computer simulation methodology helped predict if the current number of beds and operating rooms and their allocation for the various surgical services would be enough to meet the projected patient flow demand from to Using computer simulation of a number of feasible scenarios, the team determined the best possible allocation of available resources operating rooms and beds to meet the accepted criteria and estimated the implementation cost of different options.

Anderson Cancer Center were unable to schedule skin screening appointments in a timely manner. Because of the extended wait time for appointments, patients were going elsewhere for care. The center launched a project to decrease the wait time for urgent appointments by 10 percent and bring patients in for urgent care in fewer than seven days.

Anderson Cancer Center launched a project to decrease the amount of time it took for clinicians to locate patient information.

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An improvement project sought to decrease this percentage by identifying and addressing two root causes: 1 lack of training or diligence at the pharmacies, and 2 lack of awareness among patients, coupled with leniency of staff out of motivation to be patient-focused.

Charles Hospital, Port Jefferson, NY, began to explore ways to recognize and improve the reporting of pre-empted errors. While traditional reporting via the formal occurrence reporting system was encouraged, other venues for recognition and reporting were considered.

Determining that certain categories in the clinical interventions performed by pharmacy and the MAR medication administration record communications generated by nursing could appropriately be recognized as pre-empted medication errors, the team launched a project to: 1 provide a process to ensure the correctness of the MAR on a daily basis, 2 accurately capture clinical interventions performed by the pharmacy staff, and 3 simplify the process to communicate MAR corrections from the nursing staff to the pharmacist.

Identifying and addressing root causes led to a By the conclusion of the project, the incidence rate had dropped to 2. Root cause analysis identified leadership and a competitor that paid higher salaries as major contributors to turnover. The project team addressed root causes by benchmarking organizations recognized for workforce excellence and conducting leadership development training. The team also used the Baldrige Criteria for Performance Excellence to help make the workforce development plan part of organizational strategy.

Root Cause Analysis

However, many instruments were not used in the surgeries. Because of the great number of instruments in a set, there is a greater chance of counting errors, which can lead to retained foreign objects. The center launched a project to reduce the number of instruments in major operating room sets by at least 50 percent over a four-month period for abdominal colectomies removal of a portion of the colon and proctectomies resection of the rectum.

A Six Sigma waste reduction project was launched to reduce the defect of unused supplies discarded upon discharge. American Specialty Health ASH implemented a quality improvement project to educate doctors and manage the reimbursement for unnecessary X-ray exams.

Key causal drivers identified by root cause analysis included lack of evidence-based guidelines, lack of evidence-based education for practitioners, lack of practitioner knowledge and commitment to evidence-based practices, and lack of practitioner buy-in about changing entrenched healthcare decision making. Practices implemented to address root causes included guidelines development, practitioner education, utilization management oversight, credentialing and practice protocol oversight, and quality management oversight.

The year project has won national awards for changing doctor behavior while maintaining a safe and highly satisfied patient population.

Providers determine the codes and diagnoses for patient visits and are responsible for documenting care.Metrics details. Root cause analysis RCA originated in the manufacturing engineering sector but has been adapted for routine use in healthcare to investigate patient safety incidents and facilitate organizational learning.

Despite the limitations of the RCA evidence base, healthcare authorities and decision makers in NHS Scotland — similar to those internationally - have invested heavily in developing training programmes to build local capacity and capability, and this is a cornerstone of many organizational policies for investigating safety-critical issues.

However, to our knowledge there has been no systematic attempt to follow-up and evaluate post-training experiences of RCA-trained staff in Scotland. Given the significant investment in people, time and funding we aimed to capture and learn from the reported experiences, benefits and attitudes of RCA-trained staff and the perceived impact on healthcare systems and safety. We adapted a questionnaire used in a published Australian research study to undertake a cross sectional online survey of health care professionals e.

Of RCA-experience staff, 71 had assumed a lead investigator role The top three barriers to RCA success were cited as: lack of time Differences in agreement levels between RCA-experienced and inexperienced respondents were noted on whether a follow-up session would be beneficial after conducting RCA This study adds to our knowledge and understanding of the need to improve the effectiveness of RCA training and frontline practices in healthcare settings. The overall evidence points to a potential organisational learning need to provide RCA-trained staff with continuous development opportunities and performance feedback.

Healthcare authorities may wish to look more critically at whom they train in RCA, and how this is delivered and supported educationally to maximize cost-benefits, organizational learning and safer patient care.

Peer Review reports. Root cause analysis RCA is a structured approach to the investigation of patient safety incidents that is commonly applied in many modern health systems worldwide, particularly in acute hospital settings [ 1 ].

The RCA technique originated in the engineering industry as a method of identifying latent systems-based issues that contributed to underperformance, variations or design failures in mechanical production processes [ 2 ].

Its inherent principles have been adapted in many high reliability organisations — such as the petro-chemical, nuclear power, aerospace and aviation industries — to systematically uncover and improve underlying systems problems, and ergonomic and cultural issues identified as contributory factors in work-related accidents and incidents [ 34 ].

In healthcare, safety-based RCA investigations or variants of this approach were first introduced in the s to facilitate organisational learning [ 5 ]. To achieve this, a small multi-disciplinary team of appointed investigators often draws on a multitude of analytical and problem-solving techniques [ 4 — 6 ] such as Brainstorming, Pareto Analysis, the Five-Whys technique and Fault-Tree-Analysis to accomplish these aims using recommended step-wise processes Table 1.

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It should be noted that, broadly speaking, in general medical practice settings particularly in the United Kingdom UKsignificant event analysis a less rigorous investigative method based on reflective learning theory rather than RCA is the routinely applied technique of choice for historical and feasibility reasons [ 7 ].

The evidence base underpinning the effectiveness of RCA in healthcare as a method to gain an in-depth understanding of safety issues and facilitate improvements to prevent future incidents is equivocal [ 910 ].

Controlled trials to test the efficacy of the RCA framework are lacking.

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However in an evaluation of RCAs undertaken in New South Wales to identify and theme learning needs related to patient, human staff and systems factors, the authors concluded that the effectiveness of RCA as a means by which staff can achieve the desired improvements in patient care that were recommended was limited [ 10 ].


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