Medical errors aka sentinel events aka adverse events are a devastating and persistent part of our healthcare system. Solutions for long term change have been illusive and at least part of the reason for this may lie in our approach to learning from them.
In Part I of this series on Root Cause Analysis (RCA) leading expert, Robert Latino, CEO of Reliability Center Inc. in Hopewell, Va shared his preferred definition of RCA and explained the importance of asking ‘HOW’ rather than ‘WHY’ a medical error occurred.
In Part II, Bob helped us to understand when RCAs are performed typically and what really good opportunities exist for us to consider for using RCA proactively. Later in the series he’ll tell us about “Patient-Engaged RCA” which can be helpful for patients/families who have been victims of medical errors.
[Bob Latino] – There are as many way of doing RCA as there is people doing it. Usually, no matter what approach people are using to be compliant with their RCA requirements, they will call RCA. This can be simply brainstorming, 5-whys, fishbone diagrams, regulatory forms and/or logic trees.
There are huge differences in the technical capabilities of these tools. What the analyst has to understand is if they took the same case and applied each of these different tools, which would yield the most comprehensive and accurate result versus which would simply be compliant?
I wrote a paper and have presented it at numerous trade conferences, entitled ‘Root Cause Analysis versus Shallow Cause Analysis: What’s the Difference?’. I did what I explained above. I took a common case and had individuals apply the 5-whys, fishbone diagram and logic tree to it. In the conclusions, I demonstrated what critical latent root causes (management system causes) were missed when using ‘shallow cause analysis’ approaches that may be compliant…but not effective. By missing these critical causes, the event is likely to recur.
[Beth Boynton] – To offer a quick review of Bob’s paper referenced above, he compares 3 common types of RCA applied to a sentinel event involving an endobrachial fire during a bronchoscopy. The root causes of the incident identified by Reliability Center, Inc’s Proact logic tree method BUT NOT identified using the 5 Whys or Fishbone Diagram:
- Contaminated Operating Channel of Bronchoscope Source
- Purchasing Pressures to Reduce Costs
- No QC Review Process in Place When Evaluating New Vendors Offerings
- Failure to Detect Contamination Prior to OR Use
- No QC Inspection of Cleaned Instruments Prior to Use in OR
- Sufficient Additional Gases Introduced and exposed to Laser
- Mismanagement of Anesthetic Gases
Won’t the most in depth process of RCA help us to prevent the most medical errors?
Follow this series on www.confidentvoices.com where Bob will help us to understand:
- Part I-Root Cause Analysis (RCA): 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.