What Health Care Professionals & Patient Advocates Need to Know About Root Cause Analysis : Part I-What is It & Does the Definition We Use Matter to Patient Safety?

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We all know that making mistakes in healthcare is way too common and can lead to catastrophic results, including death.  Root Cause Analysis or RCA can be an extremely important component of patient safety improvement efforts.   The more we understand about this process, the more we can advocate for utilizing ‘best practices’ in the industry.  With this in mind I’ve asked leading RCA expert, Robert Latino,  CEO of Reliability Center Inc. in Hopewell, Va to help us understand critical concepts about this process.

[Beth Boynton] – What is Root Cause Analysis (RCA)?

[Bob Latino] – Unfortunately RCA is in the eyes of the beholder.  Most will consider whatever problem solving tools they are using that are meeting TJC requirements, as RCA.  Unfortunately in these cases RCA success is measured by compliance alone.  Effective RCA is measured against actual, bottom-line patient safety.  We should do an RCA on how we can have compliant RCA programs and still not measurably improve patient safety!  How we measure the effectiveness of RCA in healthcare is disjointed and needs to be revamped.  I understand The Joint Commission (TJC) is working on this.

[Beth Boynton] – What Definition do You Think is Most Helpful in Making Healthcare Safer?

[Bob Latino] – The Definition of RCA I Use is this:  RCA is the establishing of logically complete, evidence-based, tightly coupled chains of factors from the least acceptable consequences to the deepest significant underlying causes.

A. Logically Complete: This is the difference between asking ‘How Can?’ and ‘Why Did?’.  Think about the response to these individual questions and you will soon see that asking ‘How Can a medication error’ yields a   broader set of possibilities than ‘Why Did a medication error happen?’

B. Evidence-Based:  Proving what you say with hard evidence.  Hearsay is NOT hard evidence.

C. Coupled Chains of Factors: This is the difference between using ‘categorical RCA’ and ’cause-and-effect’ RCA.  By picking a category and brainstorming what may have occurred in the category, we are not linking it to the undesirable outcome.  By using ’cause-and-effect’ we directly correlate a cause with an effect and have evidence to prove it.

(Note: This is a definition that we discussed on an RCA forum where several RCA providers participated and I like it,  many did not – www.rootcauselive.com.)

[Beth Boynton] – Please Say More About the Importance of Asking ‘How’  rather than ‘Why’

[Bob Latino] In the video you and I did together (http://www.reliability.com/confidentvoices), we are trying to understand the cause(s) of a type of medication error where a nurse gives the wrong medication.  We used a Mode that stated ‘Unsafe Med Administration’.  If we asked ‘WHY’, then we would most likely explore one possibility, i.e. why the wrong medication.  BUT if we ask ‘HOW’ we open the door to investigate all sorts of other contributing factors, such as:

  • Wrong Drug Placed Adjacent to Correct Drug
  • Abnormal Number of Interruptions
  • Normalization of Deviance Paradigm (One in which doing the wrong thing has become a standard practice even if not talked about openly!)

[Beth Boynton] –  Thanks, Bob.  Your insights seem critical and helpful!

Follow this series on www.confidentvoices.com where Bob will help us to understand:

 

  • Part I:  What is it and does the definition we use matter to patient safety?
  • Part II: What Triggers an RCA to be done?
  • Part III: Are there different ways of doing one?  What makes one better or more reliable than another?
  • Part IV: What is Patient-Engaged RCA?
  • Part V:  What Role do Nurses have?  Patient Advocates?

In the meantime, listen to  Bob speak about RCA! And if you have questions, please post in a comment or email beth@bethboynton.com.

 

 

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8 Responses to What Health Care Professionals & Patient Advocates Need to Know About Root Cause Analysis : Part I-What is It & Does the Definition We Use Matter to Patient Safety?

  1. Pingback: Are There Different Ways of Doing a Root Cause Analysis (RCA)? What Makes One More Effective than Others? Part III-What Healthcare Professionals & Patient Advocates Should Know

  2. Pingback: What is involved in a TJC Survey re: a risk assessment of the Environment of Care (EOC) and leadership’s role in optimizing results

  3. To be effective, RCA MUST include a patient and/or family interview and communication throughout the process. These people are the eyes and ears of what happened. You won’t get it right if you interview just providers and review the medical record. Medical records are filled with errors of omission.

    Patients/their families or advocates often see things ‘real-time’ and they are witnesses to the continuity of care and gaps in communication that are omitted from the record and from RCA.

    The also have no reason to distort or hide the truth. And if we are ever to really get at the root causes, we need the truth.

    Patient reporting of medical errors will be piloted soon. We added family interviews (as well as adding a public member and public report) as addendum s to a bill for a maternal mortality review panel in New Hampshire legislation in 2010 and it passed. The reason was that it was based on evidence that it works (ACOG’s white paper)

    Being the daughter of a woman who died as a result of medical errors that were never disclosed to us, I see shutting the family out of RCA as unethical.
    The saying ‘Nothing about me without me’ applies to RCA and all matters related to patient outcomes.

    Thank you for this great discussion!

    • Bob Latino says:

      Thank You Lori,

      Your point is very valid about the family participation in RCA’s. To me this is the equivalent of not interviewing the witnesses at a crime scene.

      I am encouraged to hear of the bill you passed in NH requiring such patient/family participation in RCA’s. It would appear this is only under maternal mortality reviews, which is a great start.

      What has prevented this across the board is there was no regulatory driver to make hospitals include the families/patients. As a result, fears of discoverability of evidence and legal consequences trumped the decision to ‘do the right thing’.

      To take this a step further, I think we should be proactive in our use of RCA and use it to analyze unacceptable risks. Right now, RCA’s are typically only required to be conducted ‘after the fact’ when something bad has happened (reactive use). Analyzing potential events can prevent the bad consequence.

      Here are a couple of RCA videos involving the death of children you may be able to use to your benefit:

      http://ireport.cnn.com/docs/DOC-844387 – MRI Death

      http://ireport.cnn.com/docs/DOC-788256 – Staph Infection Death

      Keep the good fight going as you are making a difference and will save lives doing so.

      Regards
      Bob Latino

  4. Bob Latino says:

    Great points Meg. Good RCA analysts understand that an RCA does not end with a ‘human root’ it begins with it! Using RCA to blame someone can only result in a lack of participation by staff in the RCA…plus it is just bad practice to treat people that way.

    Effective RCA is about learning why people think the decision they made at the time was the appropriate decision.

    If a poor decision was made and then we ask ‘why’ they made that decision at the time, from a human factors standpoint we will see things like:

    1. interruptions/distractions
    2. accountability issues
    3. competency issues
    4. P&P issues
    5. overconfidence
    6. management oversight issues
    7. interface/communication between departments issues
    8. cultural norms/accepted practices

    and many more. Understanding the deficiencies in these systems and their impacts on decision making is where the real gains will be made.

    By simply blaming people, they clam up and we never truly learn why they made the poor decision. We just needed a scapegoat to appease the organization. End result….we increase the risk of recurrence of the same event somewhere else.

  5. Pingback: What Triggers a Root Cause Analysis (RCA): Part II-What Health Care Professionals & Patient Advocates Need to Know About Root Cause Analysis

  6. Beth Boynton says:

    Hi Meg,
    Thanks for your clear examples of interruptions. I think it helps to bring Bob’s point home. If you make a mistake on any of those clinical or documentation tasks you are doing and an RCA is done to determine “WHY” you made the mistake rather than “HOW”, all of those interruptions would be invisible and not addressed in the solution. Honestly, I think this helps explain the persistence of staggering sentinel events statistics despite our attempts to problem-solve. We are not always identifying the true or complete problem.
    Beth

  7. Meg says:

    Beth………another brilliant discussion !!! (applause)……and one that not only nurses need to be involved with but providers as well……..today (for instance) I can get pulled in 75 different directions..seeing a sick kid; filling out paperwork for back to school imunizations; answering phone calls; e-presribing medication; reading reports and getting at the meat of the report; talking to a specialist on the phone; documenting in an electronic medical record; answering medical assistant questions; being interrupted (consulted) by the clinic manager; all in 8 hours and…..then get it “all right” and “correct”…..

    hummmm…health care seems the oxymoron for those providing it……….the interruptions are endless……and I mean..endless…..

    thanks for thinking about this critical piece that makes it all fit together

What are your thoughts?