PS 201: Root Cause Analyses and Actions Questions & Answers

a systems approach to error asks: - "What circumstances led a reasonable person to make reasonable decisions that resulted in an undesirable outcome?" This mindset is how to actually make systems safer. latent errors/conditions - - pre-existing conditions in processes and systems that set people up for failure (e.g., poor equipment design, inadequate training, or insufficient resources). - key component of James Reason's model of accident causation, the Swiss cheese model. contributing factors (or holes in the cheese) in AE but are NOT preventable - Because Margaret has dementia, she may have had difficulty paying attention or understanding what was happening. Amy's lack of experience may have led her to make a decision that a more experienced nurse wouldn't have made. And Jorge might have taken more time to communicate effectively had he been less busy. Root cause analysis seeks to - delve deeper, to identify problems in the system that people can actually fix, understand and respond to root causes to prevent future harm root cause - a latent vulnerability in a system that allows an error to occur 7 categories of contributory factors that influence clinical practice (Charles Vincent) - Institutional context Organizational and management factors Work environment Team factors Individual staff members Task factors Patient characteristics a cause and effect diagram or 'fishbone' diagram - tool that helps teams identify contributory factors and visually group them five whys was created by - Taiichi Ohno, father of the Toyota Production System, which revolutionized automobile manufacturing with methods now known as Lean. five whys exercise/analysis - asking 'why?' again and again until you reach the root cause five whys example - Why did the patient receive the wrong medication? The nurse did not complete patient identification. Why? The patient did not have a wristband. Why? The wristband had been removed for a procedure and not replaced. Why? The printer for the wristbands was not working. Why? ROOT CAUSE: The staff needed to support IT had been reduced and was overworked. Five Whys Example: Mrs. Smith is an elderly patient with congestive heart failure, admitted to hospital every 6 weeks. - • Why? o Fluid in lungs causing shortness of breath • Why? o The sodium content was building up causing fluid retention • Why? o Patient was ingesting too much sodium or the diuretics weren't working well enough • Why? o Patient lacked the knowledge and support to manage her diet and drug regimen • Why? o ROOT CAUSE: Patient education process is ineffective and support systems don't exist when they go home RCA is problematic because: - 1. the term implies that there is one root cause. As you are seeing, this is rarely true. Health care is complex, and many contributing factors must be considered in understanding why an event occurred. 2. the term RCA suggests that analysis is the ultimate goal. But knowledge alone will not prevent the same event from happening again, so the ultimate purpose should be action. RCA2 stands for - root cause analyses and action need for RCA2 - many techniques exist for investigation and action following an AE but are vague, varied, yield inconsistent results (not standardized, fail to identify system-level causes, superficial solutions 'try harder', poor implementation of effective solutions) RCA2 helps because - o Multiple causes usually contribute to an adverse event o Emphasis on ACTION o Standardize process o Risk-based (not severity-based) prioritization o Goal = effective action + sustainable results key components of RCA2: - Active leadership engagement and support A non-punitive approach Transparent, risk-based prioritization Timeliness Effective team composition and patient engagement The application of tools including triggering questions, the five rules of causation, and the action hierarchy Providing feedback and celebrating wins timeline for RCA2 - - assigning people to be 'on call' if an unintended event occurs - once safety is restored: thoroughly document what happened while still fresh, sequester any drugs/equipment (keep them exactly as they were; do not experiment with equipment to determine malfunction) - w these steps completed, a patient safety professional should determine within 72h whether event qualifies for RCA2 purpose of RCA2 - undercover and correct systems failures RCA2 is specifically NOT for - inflicting blame or punishment RCA2 should never be used for - blameworthy events (a case where someone acted with intentional disregard for safety; these should be handled through HR systems) harm-based prioritization - Most organizations rely on harm-based prioritization. This means after patient harm occurs, providers focus their efforts on cases that caused the most severe harm. RCA2 experts recommend using risk-based prioritization because: - - It considers close calls and near misses as opportunities for improvement. - It considers probability of harm as a key factor in allocating limited resources. within X hours of incident a person from PS, risk, quality management should perform _______. Having the _____ person do the assessment is recommended as a _____ ______ and applying a ______ ________ _______ can be helpful - 72 h perform risk-based prioritization, having the same person is recommended as a control factor and applying a risk matrix tool can be helpful safety assessment code matrix (risk-based prioritization) - Using the risk matrix, first locate the potential severity rating, and then follow the column down until you reach the row containing the probability score. safety assessment code matrix severity categories - • Severity categories: catastrophic, major, moderate, minor safety assessment code matrix probability categories - • Probability categories: frequent, occasional, uncommon, remote Example of applying risk-based prioritization: • A pacemaker failed to work, putting a patient in danger • Repeated attempts to fix the pacemaker (turning it off and on) did not help • Investigation revealed the same failure happened every 9 months - • Catastrophic category, occasional (every 9 months): level 3, would get action At your hospital, where you're a patient safety officer, nursing staff members were providing routine morning care to a patient. They were washing a patient who was seated in a chair. As this was taking place, he slid off the chair, hitting his face, hip, and shoulder. The patient was examined by a doctor at 7:55 AM and transferred to radiology for further evaluation. The physician ordered x-rays and saw no fractures. Additional neurology checks were reported as normal. 1. You are evaluating whether an RCA2 should be performed on this event. What would you say is the actual severity of this event? a) Catastrophic b) Major c) Moderate d) Minor. 2. What do you think is the potential severity of this event? a) Catastrophic. b) Major c) Moderate d) Minor 3. Assuming you judge the probability of a patient experiencing the most severe outcome as "occasional," should the organization proceed with RCA2? a) Yes b) No - 1. the actual severity is minor, no injury was reported after evaluation by x-ray and clinical evaluation on the ward 2. potential severity is catastrophic, You should be able to imagine a worst case scenario in which the patient's fall results in a lethal injury. 3. yes, you need an RCA2 because catastrophic + occasional = score of 3 (any probability + catastrophic is a score of 3) score of 3 on safety assessment code matrix - catastrophic severity + any probability major severity + frequent probability *all events w score 3 require RCA2* To ensure prompt action after something goes wrong, the investigation portion of RCA2 be completed in no more than - 30-45 days