Recycling Part IV of this series about RCA
With the persistence of medical errors, aka sentinel events, aka adverse events in our healthcare system it seems critical for consumers and healthcare professionals to understand best practices in Root Cause Analysis, RCA so that WE can advocate for 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.
In Part III, he explained how different approaches to RCA can provide more (or less) comprehensive information about what contributed to an adverse event and how we can use the in depth analysis to provide more effective prevention of recurrence.
In today’s segment, Bob explains how the victims and or families of a catastrophic medical accident can be involved in the RCA process.
[Bob Latino] – While I primarily work to educate investigators in clinical care settings on how to properly conduct an investigation, many organizations are not as forthright as others about seeking or finding the ‘truth’ from an RCA. As a result the analysis is conducted strictly from a legal perspective rather than a safety perspective. This is unfortunate because by covering up the truth (the deficient management systems providing poor data for decision making) the facility has increased the chances of recurrence. In addition, victims and families who have suffered from an medical error also suffer from a process where the truth of what happened to them is elusive or even obscured.
In such cases, I have worked with families that have been harmed by a facility and the family is interested in finding the truth, if for nothing else but closure to know what happened to their loved ones. Obviously families are more motivated to find the truth than some of the care giving organizations, so they approach RCA with a vigor. Unfortunately, they require cooperation of the facility in order to get data to support or refute their hypotheses. Usually under such conditions, the wagons are circled and getting such data is a challenge compromising their ability to find the truth. This is unfortunate about litigation as it polarizes the two sides and they dig on their respective positions and evidence is then suppressed in many cases because it will only be presented if it helps one side or the other. Safety investigations do not focus on a winner and a loser like a court case, safety investigations focus on the truth!
Read and listen to this Mom’s moving story on this Patient-Engaged RCA involving the tragic death of 11 year old Justin Micalizzi who was undergoing a ‘simple’ surgery on his ankle.
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.