(Recycling important series on RCA with permission from Bob Latino)
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. (This point is crucial-see Part I!)
In Part II, Bob helps 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.
What triggers an RCA to be done?
[Bob Latino] – Usually there are regulatory triggers that determine the threshold for conducting RCA. Some common triggers are Sentinel Events and Never Events. Unfortunately, normally something really bad has to happen before we apply RCA. This is why current regulations foster only the reactive use of RCA. What about all the unacceptable risks identified in an failure modes and effects analysis (FMEA) or all the chronic failures that occur every shift of every day that do not rise to the severity of a Sentinel Event?
We should be doing RCA proactively to avoid the need for its reactive use. However, since the proactive use of RCA is not REQUIRED, most don’t do it. We should do it because ‘it is the right thing to do’ not because somebody makes us do it.
Can You Do an RCA on Something Bad that Might Happen?
[Bob Latino] – Contrary to popular belief, you can do an RCA on an unacceptable risk. The logic tree, a step by step question and answer process that leads to information about the cause(s) of an error, would start with the EVENT of ‘Unacceptable Risk of XXX’. For instance, a nurse notes that discontinued narcotic medication is in the med cart and sees this as a potential error waiting to happen. We could take this potential risk of error and ask ourselves ‘How Could’ this risk be so high? This way, we start to uncover the reasons BEFORE an accident happens. Then we can take actions to reduce the risk in an effort to ensure the risk does not materialize (no need for reactive RCA after bad consequences are realized). The same goes for doing RCA on high frequency, low impact failures or chronic failures.
Give Us an Example of a Problem Where RCA is not Required, but Would be Helpful
[Bob Latino] – To make my point about the impact of chronic failures that usually go under the radar, we completed an analysis which demonstrated the cost of blood redraws in a single hospital’s ED (225 bed acute care facility) was over $3,000.000/yr. This was found by calculating the average cost of a redraw (of $300) x the frequency of occurrence (which was 10,000 times per year). Does the TJC make you do RCA on redraws…NO. Should you do RCA on redraws….YES! To learn more about the Blood Redraw Case see: http://www.reliability.com/oa.html.
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?