(Recycling part V of this important series. Links to I-IV are at the end of the post!)
Long term effective solutions to persistent issues in patient safety will be more likely if we understand the process of Root Cause Analysis (RCA) so that we can learn the most from medical errors, aka sentinel events, aka adverse events. In this final part in the series on Root Cause Analysis (RCA), leading expert, Robert Latino, CEO of Reliability Center Inc. in Hopewell, Va shares his advice about the role that frontline staff and patient advocates play in best practices in Root Cause Analysis, RCA. (To learn more about the inside scoop on RCA, scroll down for links to Parts I-IV.Nurses know the 'truth' whether the analyst wants to hear it or not. Click To Tweet
What role do nurses have? Patient advocates?
[Bob Latino] – Contrary to popular belief again, RCA’s are not a managerial exercise conducted behind closed doors and they emerge with THE ROOT CAUSE. I have always been a firm advocate that those closest to the work (the sharp end), are a critical requirement of any RCA team. Obviously in most cases, this is the nurses. Nurses know the ‘truth’ whether the analyst wants to hear it or not. This perspective is absolutely necessary to conduct a comprehensive and accurate RCA. Without such input, the quality and integrity of the analysis suffers and increases the risk of recurrence of the event at hand. I consider patient advocates as the ‘patient-engaged’ population I spoke of in Part IV of this series. I believe that more hospitals, those interested in the ‘truth’ as opposed to simple legal protection, should do more to engage patients and their families (advocates) in the internal RCA’s. Obviously there are many legal considerations in doing this but if there is unity in purpose of the investigation that the truth is what they both seek, both parties will be a critical requirement. Those who seek to do RCA’s simply for compliance purposes relegate themselves to the following paradigm: “We never seem to have the time and budget to do things right, but we always seem to have the time and budget to do them again” Can we afford to do ‘shallow cause analysis’ and continually pay claims for the same event over and over again? Thanks to Bob Latino for his help in teaching us these important concepts about Root Cause Analysis. As health care professionals and patient advocates align to insist on safe, quality care, our impact will surely be more profound with such knowledge. Learn more about RCA with links below or listen to Bob speak about RCA! ! 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 Part IV, Bob shares his process and advice on the value of “Patient-Engaged Root Cause Analyis”, where families of victims are involved! Comments are always welcome!