Helping organizations in mapping risks
The following types of incidents are not recommended for a system-based analysis:
1. Events thought to be the result of a criminal act;
2. Purposefully unsafe acts (an act where care providers intend to cause harm by their actions);
3. Acts related to substance abuse by provider/staff; and
4. Events involving suspected patient abuse of any kind.
The RCA seeks to answer four questions:
1. What happened?
2. Why did it happen?
3. What are we going to do to prevent it from happening again?
4. How will we know that the changes we make actually improve the safety of the system?
It is hard, if not impossible, to answer the questions related to the goal and purpose of the RCA alone. Health care is complex, and understanding what led to an error requires diverse perspectives on how the system really works. In an RCA, an interdisciplinary team approach is used to understand the specific error that occurred.
Consequently, the first step in the RCA is to form a team.
Typically, an RCA team consists of four to six people. The team should be interdisciplinary, and it should include individuals at all levels of the organization who are close to and have fundamental knowledge of the issues and processes involved in the incident.
In addition, members of the risk management and/or quality improvement departments are helpful to have on the team, as they can often provide an unbiased view of the incident and serve as a facilitator.
Experts disagree about whether people involved in the event should be on the team. Some feel that these individuals can provide a unique and valuable perspective, while others think the process is too difficult for the individuals involved in the event and can bias the team’s ability to identify causes and solutions.
Typically, RCAs are conducted by individuals who were not part of the initial event to provide a set of “fresh eyes” on the circumstances, although, they will play a key role in the RCA.
Some RCA teams include patients or family members. Again, experts disagree about whether to include these individuals. If patients and family members are able to analyze the factors contributing to an error without becoming overwhelmed by their emotions, their perspectives can be extremely valuable. However, if they are unable to remain objective, they can negatively impact the analysis. Some RCA teams include patients and family members who are interested in improving care but weren’t involved in the specific error at hand.
It is also important that the clinical and administrative leaders in the hospital are supportive of the RCA and provide time and resources for the RCA to be completed. RCAs require a considerable amount of time and work and may lead to many ideas for process improvement; team members often need to be relieved from some of their usual duties so they can focus on this work. While leaders can lend their support also by participating on the team, this is not necessary. What is required is a commitment to support the members who are on the team and help them participate fully.
Once the team is formed, members typically agree to fill certain roles:
There is no right or wrong answer. It really depends on the comfort level of the organization and its culture. In some organization, including senior leaders could help address any barriers to change and improvement while in others, if senior leaders are on the team, people may feel intimidated when asked about what happened.
During RCA, the team spends time reviewing and discussing what happened? Team then goes on and identifies some key gaps between ideal process and actual process, identifies, causes and creates recommendations.
Gap analysis may include reading through current organizational policies, reviewing medical literature, or interviewing department directors to find out about barriers to safe practice. Team is in a better position to observe the differences if they create a flow chart of what happened as well as wat should have happened. Facilitation can then ask the question to the team to think of reasons that patient’s care did not actually follow the plan as per the second flowchart.
For any incident once should explore into both direct causes and contributory factors. As the name implies, direct causes are the most apparent or immediate reasons for an event. Although direct causes can be easy to identify, they are not usually the causes that ultimately influence whether the event will occur again. In other words, direct causes can be symptoms of another, larger (“big-bucket”) problem.
Contributory factors – for example, staffing issues that make care provider’s day hectic, a failure to use proper procedures for patient handoffs, and weak communication between care providers – are more indirect in nature and are the ones on which we want to focus.
The best way is to ask “Why?” – and ask it a lot.
Some experts recommend that RCA teams “ask why five times” to get at an underlying or root cause. With this approach, teams don’t just ask "Why did this happen?" and settle for the first answer that presents itself. They ask "Why?" again and again until they reach a root cause. This exercise can lead to surprising insights and can help teams avoid “quick fix” solutions – especially for chronic problems that show up over and over again in a system.
David, a laboratory assistant, is cleaning a part of the laboratory where residents perform dissections. He started working in this department three days ago. As he cleans the sink in the dissection area, he accidentally runs her thumb along the length of a dissecting knife, cutting her finger open. The injury requires 10 to 15 stitches, and he cannot work in the lab for two weeks while the injury heals.
To prevent this type of event from occurring again, the laboratory pulls together a team to do an RCA. After flowcharting what happened and what should have happened, the team begins to look for causes. They start this process by asking, “Why?”
1. Why did this happen?
Answer: The knife was left by the sink.
2. Why was it left by the sink?
Answer: The area was not cleared on the previous day.
3. Why was the area not cleared?
Answer: Clearing is not a daily habit.
4. Why is it not a daily habit?
Answer: Standard operating procedures/documentation for clearing do not exist.
5. Why is that the standard operating procedures / documentation does not exist?
Answer: The organization does not have a training program related to standard operating procedures and safety assessments.
After asking these five questions, the team finally gets to a root cause of the problem: Lack of training on Standard Operating Procedure and Safety assessments. This is a cause that, if addressed, can possibly prevent the similar event from occurring again.
This example is fairly straightforward and involves only five questions. In complex RCAs, multiple “ask why five times” exercises may be necessary to identify the multiple factors contributing to a problem.
Another tool that has worked well for me is called Fishbone diagram. We probably don’t have time to go into details for that one today, but I feel that can be our next webinar!
When something goes wrong in a patient’s care, we tend to identify people as the cause. However, a person can’t be a root cause. People are actors, not causes. Accident investigator and human factors expert Sidney Dekker reminds us that “cause is not something you find. Cause is something you construct.” 6
When we find that a person has done something that led to an adverse event, we have to think about why that person would think that was a reasonable thing to do. Dekker writes, “The point of an investigation is not to find where people went wrong – it is to understand why their assessments and actions made sense at the time.”
Creating causal statements can help in constructing causes. A causal statement links the cause to its effects and then back to the main event that prompted the RCA in the first place. By creating causal statements, we explain how the contributory factors – which are basically a set of facts about current conditions – contribute to bad outcomes for patients and staff. A causal statement has three parts:
1.The cause (“This happened…”)
2.The effect (“…which led to something else happening…”)
3.The event (“…which caused this undesirable outcome.”)
In the earlier example of David and the dissecting knife, the cause is the lack of standard operating procedures training and safety assessments. The causal statement might go something like this: “The lack of standard operating procedures and documentation training [the cause] increased the likelihood that SOPs for cleaning will not exist [an effect] , which increased the risk that David would cut his finger [an effect], which led to the need for stitches and lost work [the event].” As well, “The lack of safety assessments for tasks[the cause] increased the likelihood that hazards such as sharp knife being left in or around the sink [an effect] , which increased the risk that David would cut his finger [an effect], which led to the need for stitches and lost work [the event].”
Causal statements are both the “what” and the “why” for the adverse event.
I want everyone to know that an RCA is the most useful mechanism to improve safety and it works well when the causal statements lead to actionable improvements.
Well, there are some helpful rules to keep in mind when writing causal statements:
1. Root cause statements must clearly show the “cause and effect” relationship.
2. Statements should include neutral language and not imply judgment or blame.
3. Each human error must have a preceding cause.
4. Violations of procedure are not root causes; they must have a preceding cause.