As patient safety evolves, we've shifted our focus from reacting to events to putting procedures and cultures in place that focus on prevention. The growing popularity of root cause analysis (RCA) is related to that shift.
What is root cause analysis?
Root cause analysis is a systematic process that seeks to answer many questions and provide opportunities for learning. In general, an RCA tries to answer:
What was supposed to happen?
How could this situation have occurred?
How can we prevent it from happening again?
Most of us think of RCAs in relation to meeting regulations and credentialing. The Joint Commission established its formal policy on sentinel events over 20 years ago. Which events are considered sentinel varies depending on the type of healthcare organization but they're all considered serious, and need to be investigated and responded to immediately. Healthcare organizations are required to conduct a comprehensive, systematic analysis and create an action plan in response to a sentinel event within 45 business days of the event or of becoming aware of the event.
In addition to TJC rules, many states and provinces have their own RCA regulations and individual hospitals have guidelines for what type of event mandates an RCA. But once we look beyond what you have to do, we can see the potential for RCA as something you want to do. And this is where things start to get really interesting!
RCA for learning and proactive prevention
Most healthcare organizations have procedures in place for conducting RCAs but they neglect to share the results. This is a crucial step for promoting learning. For example, the IHI talks about the importance of sharing the RCA findings with everyone who could experience the same error.
Other studies point to the importance of approaching RCAs with a system's mindset, taking into account that there are people involved in every situation. The goal of an RCA is not to blame and shame but to identify underlying contributing factors so that measures can be put in place to prevent a similar occurrence in the future.
Once your RCA process is firmly established, you may want to approach proactive RCAs. Reliability Center Inc. explains that RCA is typically considered a reactive tool but it has the potential to be proactive: "RCA should be used in concert with RCM [reliability centered maintenance] and other risk analysis tools to provide a holistic approach to eliminating failure, to build a culture of safety." In RL6, users can recommend events for a root cause analysis by sending adverse event or patient feedback files to the Root Cause module.
Apparent Cause Analysis
One of the drawbacks to RCAs is the amount of time it takes to complete them effectively. From interviewing everyone involved, reviewing charts, documenting and sharing the results, organizations often don't have enough time to investigate all of the events they want to. In response, some hospitals have pivoted to apparent cause analysis (ACA) investigations. These limited investigations have two purposes: identify actions to address the problem/immediate condition and collect event information to aid in the identification of organizational trends (Source: Children's National). ACAs are especially effective for less significant events that don't need to be reported to regulatory bodies.
Share how your organization is using root cause analysis to drive patient safety improvements in the comments below!