Last month we published a blog post about moving from reactive to proactive with root cause analysis (RCA). Increasingly, RCA is a requisite step for organizations to learn from errors, fill in knowledge gaps and ultimately reinforce a culture of safety.
There are several ways organizations can choose to conduct an RCA. The Joint Commission model, VA model, The London Protocol, and RCA2 are all recognized frameworks for performing an RCA. While they may differ in methodology, they serve a common purpose: to investigate the chain of events that result in an adverse outcome, to illuminate inadequacies that contribute to an event and eventually reduce or eliminate recurrence.
What's in a name?
According to the authors of the London Protocol, “root cause analysis” is a bit of misnomer because it suggests that incidents have a single causal factor, when often they are far more complicated.
Imagine the following: a nurse gives a patient the wrong dosage of insulin, resulting in an episode of life-threatening episode of hypoglycemia. Our initial instinct is to quickly point fingers at the attending nurse, right? But it might not be so simple. Perhaps the nurse was exhausted – a consequence of being at the end of a 12-hour shift because of staffing shortages and budget cuts.
We could also put the blame on the pharmacist who labelled the syringe. But maybe she was a pharmacy resident that incorrectly calculated a dosage, and hesitated to tell her supervisor, because she was worried about repercussions. And what about the patient’s family? Their distress over the hospitalization and micromanaging of the staff could also have contributed to the mistake.
The truth is that in this case, and most others, no one individual carries all the blame. Evidently, each incident that happens in a healthcare environment is the result of a complex, dynamic web of interactions, as opposed to a single definitive blunder from one individual. Performing an RCA should be a paradigm shift that places emphasis on the culture of safety, and away from blame and disciplinary action.
Latent versus active failures
The London Protocol lists the following factors that influence clinical practice:
- Patient factors
- Task and technology factors
- Individual (staff) factors
- Team factors
- Work environmental factors
- Organizational & management factors
- Institutional context factors
This framework is based on the broader systems approach of identifying latent failures and active failures. Detecting latent failures (such as overarching organizational and regulatory standards) and active failures (which often occur during a point of interaction between an attendant and a patient) allow us to understand the string of events that occur before an incident happens. To continue with the insulin dose example, a latent failure could be the lack of guidelines around proper labelling at the hospital, while an active failure could be the nurse’s lack of attention.
However, the multifactorial nature of adverse events should not impede an organization's motivation to encourage change. It is imperative that learnings are discussed, and that action plans are implemented, with constant iteration based on evidence-based recommendations. The value in an exhaustive investigation is seen when the discoveries are relayed into terms that allow healthcare organizations to prevent future harm.
Measuring the effectiveness of root cause analyses and the results of their recommendations is another critical component to continuous improvement in healthcare. Research suggests that an evaluation of the effectiveness of an RCA process is needed to determine the best method of decreasing the likelihood of event recurrences. The process may be complicated, but at the end of the day, this is all done in the name of patient safety.