Should Nurses & Advocates be Involved in Root Cause Analysis? What Healthcare Professionals & Patient Advocates Need to Know-Part V

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(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!

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7 Responses to Should Nurses & Advocates be Involved in Root Cause Analysis? What Healthcare Professionals & Patient Advocates Need to Know-Part V

  1. Pingback: What Triggers a Root Cause Analysis (RCA) & What Should, but Doesn’t? Part II-What Health Care Professionals & Patient Advocates Need to Know

  2. Pingback: Is it Silence that Kills or is Silence a Symptom of Much Deeper Problems?

  3. Bob Latino says:

    Joleen

    Point well taken. This is the politicizing of RCA where we want to give the appearance of being ‘fair and balanced’ but we are not. This is a sure fire recipe for having to deal with the recurrence of the same type of event in the future. Unfortunately, what you describe happens all the time. In the second RCA, it should be noted the first RCA was ‘not effective’ because of the ineffectiveness of such panels due to the competing agendas of the members. The first RCA was also either insufficient/inadequate or it was sufficient/adequate and not properly acted on.

    Meg

    True RCA is about being balanced. This requires our being open and willing to take a hard look at ourselves as potential contributors to the bad outcome. But this does not mean that the families are exempt from an equally intense look at their contribution. If they are open and willing to participate, they have to be open and willing to have the microscope put on them as well.

    Typically the vastly difference perspectives provide a much more synergistic outcome because each party is sympathetic to the reasoning of the other side. This is even if their paradigms are incorrect because of a misconception about the other side that would be cleared up in such an RCA team meeting.

    Thanks for your helpful and thoughtful comments.
    Bob

  4. Meg says:

    I think..root causes are far too multiple: yes it is an administrative legal nighmare to involve families; yes the economic fallout can be devastating; but “protecting” a hospital; a doctor etc in the event of a very bad outcome when this outcome could have been prrvented needs to be addressed with all parties including families. However; families are equally responsible: I say this because the root cause doesn’t just lay with the bad outcome: it starts well before that. I t starts with families pushing their youngsters to play dangerous sports; engage in dangerous activities; we can’t “fix” this and the inherant risk involved: so all parties are involved; so if you want to get at the truth of things: everything needs to be “on the table” not just chosen issues: everything. The entire truth of the entire event; start to finish.

    • Beth Boynton says:

      Absolutely, Meg. Getting at the “entire truth” is critically important. And…we all have to be accountable, informed, and responsible stakeholders. This isn’t going to happen with a pill or on-switch, but increase awareness, dialogues, transparency, and commitment to safer, kinder, more cost-effective care. AND best practices in RCA!

  5. Joleen Chambers says:

    When FDA can populate panels with industry insiders and hand select non-voting patient reps through OSHI office of special health issues, we will continue to get implantedmedical devices “garbage in: garbage out”.

    • Beth Boynton says:

      Joleen,
      Thanks for your comment. Sounds like you have some insights about RCA with respect to medical devices. I’d appreciate learning more through a more detailed comment, or perhaps a guest blog post?
      Beth

What are your thoughts?