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 firstname.lastname@example.org.