Patient-Engaged Root Cause Analysis (RCA): Preventing & Healing from Sentinel Events

FollowFollow on FacebookFollow on Google+Tweet about this on TwitterFollow on LinkedInFollow on TumblrPin on Pinterest

On January 15th, 2001, Justin Micalizzi, a healthy 11-year old boy, was taken into surgery to incise and drain a swollen ankle. He was dead by 7:55 a.m. the next morning, leaving behind two grieving and bewildered parents who desperately wanted to know why their son had died.

But medical care was to fail them twice:

– first,  their son died

– second,  no one would explain to them why.

(excerpted from “A Family’s Search for Truth,” Patient Safety and Quality Healthcare, Nov/Dec 2006)

Earlier this month, Bob Latino, CEO of Reliability, Inc. Tricia Pil, MD released a video of a Root Cause Analysis, (RCA) that included the compelling and heartbreaking perspective of Justin’s Mom, Dale Ann Micalizzi.  It is called, “Sudden And Unexpected Intraoperative Death”.

As a mother, it is almost too painful to even think of this family’s tragic loss.  And then on top of it the betrayal of trust in the silence from the hospital that permeated the aftermath.

Yet, as a nurse, I know all too well how sentinel aka adverse events can happen.   Much easier,  perhaps than we can defend or explain with staggering and persistent statistics from the Joint Commission.  AND YET, how can we prevent them if we don’t dig deep into sentinel events with the intention of  seeking to understand rather than covering up?

And doesn’t the family deserve to be part of the process?  Certainly this helps healthcare professionals to stay connected with the emotional consequences of our ‘failures’ and consumers to learn more about our world.  They become more empowered and stronger, more credible advocates.

Healthcare consumers bring their injuries and illnesses to us in good faith.  That we will do our best to provide safe and quality care for themselves and loved ones.  They are vulnerable and trusting.   Sometimes I think we trivialize this part of the relationship.  We maintain silos of ‘us’ vs ‘them’.  Rather than being resources and team leaders, at times we take on a role of managing their lives.  Then something goes wrong and we abandon them.  It seems we nurture the dependence and when threatened and sever all ties.

When asking CEO, Bob Latino about the Patient-Engaged RCA process he stated, “It demonstrates a sincere interest in finding the truth, promotes transparency and is the beginning of the healing process for the victims. As the video demonstrates, ‘silence’ produces the opposite effect and polarizes the two parties instead of bringing them together for a common purpose.”

I believe Patient-Engaged RCA  is a landmark effort in bridging the gap between healthcare professionals/organizations and patient advocates. Please reserve 20 minutes of your time to watch, offer feedback and share this video.  “Sudden And Unexpected Intraoperative Death”.    It may be scarey and complicated from a liability standpoint, but we will be so much more powerful in providing safest care if we are aligned with full and truthful disclosure.

Hat’s off to Bob, Tricia and Dale,  for this progressive effort in patient safety.

My heart felt condolences to Justin’s family.

Learn more about the work Justin’s Mom is doing at Justin’s Hope-The Task Force for Global Health




Print Friendly, PDF & Email
This entry was posted in Communication in Healthcare, Complexity in nursing, Medication Errors, Patient Advocacy, Patient Safety and tagged , , , , , , , , , , , , , , , , , , . Bookmark the permalink.

2 Responses to Patient-Engaged Root Cause Analysis (RCA): Preventing & Healing from Sentinel Events

  1. Beth, thank you very much for having the courage to post this very important video! The points made in this video impact every patient in the healthcare system and it was intended as a proactive attempt to ensure that what happened to Justin does not happen to someone else’s child. I also applaud and admire Dale for her never-ending commitment to prevent other parents from going through what she did.

    I have been in the RCA business for nearly 30 years and have applied it in nearly every industry you can think of in over 20 countries around the world. Proper RCA is not industry specific at all, it is human specific. The common denominator of all undesirable outcomes is that a human will have to use their deductive reasoning to understand exactly what went wrong. To me, proper RCA is the same as excellent critical thinking skills.

    I spent the early part of my career facilitating RCA’s in oil refineries, paper mills, steel mills, power plants and the like. Helping my clients solve complex issues that were resulting in injuries, regulatory violations and lost production ($$$ losses). Good engineers are relentless at RCA in industry and understand that beneath the ‘what broke’ part of the analysis, a human will be involved as they made an inappropriate decision to do or not do something. Stopping there is equivalent to ‘witch hunting’ and not acceptable. A good RCA starts with the human being and does not end with it. An excellent RCA analyst knows that a true RCA will determine ‘why’ someone made the decision at the time they did and this will uncover the truth…deficient organizational system. These are our policies, procedures, training mechanisms, purchasing systems, incentive systems, interface management systems, etc. These are the systems put in place to help us make better decisions. These systems, over time, can become obsolete, inadequate, insufficient and in many cases are non-existent from the beginning.

    My work in healthcare with hospitals finds that while there are pockets of excellence, many define success of their RCA’s with being compliant. The disconnect I find with this seemingly admirable goal, is that I can find no study that directly correlates a compliant RCA effort with improved patient safety. This often allows shallow cause analysis tools to be acceptable because they can pass compliance but not be up to the RCA standard of actually impacting patient safety. This unveils a compliance issue where the regulatory standards are too loose and misdirected. Such RCA regulations should be measured against patient safety metrics instead of just a checklist of tasks that were completed. RCA’s should be measured by their effectiveness and not the fact that a checklist was complete and recommendations made. Were the recommendations implemented? If so, did they improve patient safety? How?

    Most do not realize that an RCA is equivalent to a safety investigation and not a criminal investigation. RCA is about uncovering the truth under any circumstances. This means we are not interested in ‘who’ made a poor decision, we are interested in ‘why’ they thought it was the right decision at the time. This drills deeper into the systems we spoke about earlier. RCA welcomes all evidence whether it supports our belief or not, because we are interested in the facts leading us to the truth, not what we would like the truth to be.

    A criminal investigation is much different. In a criminal investigation there is a winner and a loser. The plaintiff must state their position and then defense must build a case to discredit the plaintiff’s position. This means that evidence now becomes polarized. Evidence that supports my position, I will readily accept. Evidence that does not, I will seek to refute or discredit. This is called ‘confirmation bias’. So not all evidence in a criminal case is handled an openly as in a safety investigation. The purposes of each investigation are very different and therefore their outcomes are different.

    In my work recently with Patient Safety Advocates, I am learning they have an understandable yearning for the truth and they deserve it. They are motivated to uncover the truth because they have been harmed and many have lost loved ones. They are interested in a true safety investigation style RCA. However, when we look at the other side of the tracks with the hospitals involved, oftentimes their motivation is more legally-oriented and that is why the wagons sometimes circle with regards to evidence.

    How hospitals handle apologies and whether this reduces claims overall or not, is a completely different issue for another forum. However, from my personal viewpoint, helping patient’s and their families’ harmed find the truth is a moral obligation and not a legal one. It is simply the right thing to do!

    Food for thought: We never seem to have the budget and time to do things right, but we always seem to have the budget and time to do things again!

    Bob Latino
    Reliability Center, Inc.

    • Beth Boynton says:

      Hi Bob,

      Thanks for your very helpful comment. It IS a moral obligation to involve families in the process of Root Cause Analysis.

      I think we are afraid of the truth at times. Our cultures tend to blame individuals which encourages a negative cycle of defensiveness and fear of truth & accountability. Fears about job security, risking our licenses, loss of confidence or self-esteem and maybe even public shame on the part of individuals. Organizational leaders may fear loss of revenue, expensive fixes, loss of leadership power or credibility. All of things things interfere with objective pursuit of understanding.

      There is also an expectation that nurses and doctors are angels or gods. We are not. We are human beings. Individual healthcare professionals, consumers and organizations, such as hospitals and clinics must take this in.

      Further, I think we are on the shore in terms of empowering patients and this is complicated because different consumers are all at different places with respect to interest and capacity for understanding medical and nursing interventions. The Patient-Engaged Root Cause Analysis (RCA) that you, Tricia, and Dale did is a major step forward.

      In my early career, I was a workers compensation nurse case manager and worked with many industries. I was always intrigued about the human factors involved among stakeholders. The injured employee, the manager, HR, the insurance adjuster, maybe an attorney and the gray, sometimes messy stuff like their relationships, motivations, fears, power/leverage all seemed to impact the employee’s recovery. Tough to measure, yet palpable and powerful.

      Your comment has so much valuable information about RCA in it that I hope to break it down and ask you to elaborate on it in the future. I hope that you will help do this with me.

      For readers who are interested in learning more, Bob’s team at Reliability Center, Inc. is offering a FREE webinar w/ Q & A on June 13, 2012. Check it out here:

      BTW, I HIGHLY recommend working with Bob Latino. In my experience on an earlier RCA, I went from worries and fears and defensiveness to a developing trust and increase in understand. You can sense that he cares and is not judging. FYI- The one we did was called: “RN Administers Wrong Medication to Patient”:


What are your thoughts?