Patient Safety: Root Cause Analysis, Slides of Nursing

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Patient Safety: Root Cause Analysis

Lisa Ayoub-Rodriguez M.D. Credit to: Heidi Lyn M.D. Session time: 1:40pm – 2:25pm

Objectives

• Become familiar with the use of Root Cause Analysis in evaluating adverse outcomes in patient care
• Identify root cause/contributing factors in a given case.
• Categorize the root causes/identifying factors
• Suggest an action plan based on the factors identified.

Sentinel Event

• An unexpected occurrence involving death or serious psychological or physical injury, signaling the need for immediate investigation and response.

Process for Root Cause Analysis

• Step 1 – Investigate the Occurrence
• Step 2 – Identify Proximate Causes
• Step 3 – Identify the Root Cause
• Step 4 – Identify Previous Missed Opportunities
• Step 5 – Develop Corrective Actions

Identify Proximate Causes

• Qualify, validate, and verify all information collected in the investigation.
• Conduct a literature review of evidence- based practice and best practices. Include a search for Sentinel Event Alerts on the Joint Commission website.

Identify the Root Cause

• The process is the focus, not individual performance.
• The event or combination of events that initiate a failure.
• Consider WHY the individual committed the inappropriate act.
• Determine HOW the system influenced the individual’s thinking.
• Root Cause
  • Event or events that initiate failure
• Contributory Cause
  • Did not initiate the failure, but contributed to the outcome

Identify Previous Missed

Opportunities

• Determine whether previous similar occurrences have happened in the past
• Evaluate the effectiveness of corrective actions for these events

Develop Corrective Actions

• Include remedial and interim actions to reduce the risk of occurrence during the short term
• Assure robust corrective actions that address the Root Cause(s) and Latent Factors

Example

• A patient in a locked ward was found on the floor in his room with 3rd^ degree burns to his chest and arm. The patient had last been seen requesting a cigarette. A partially burned restraint was still attached to the patient’s wheelchair.

Brief Timeline

• Patient in locked ward
• Patient in wheelchair
• Restraint used to maintain position in wheelchair
• Patient requests cigarette and lighter
• Staff provide smoking materials - Short staffed - Patient left unattended - Patient uses lighter to ignite restraint - Restraint burns and patient slips out of chair - Patient found burned, laying on floor

Guidelines for Corrective Action Plans

• RCA Corrective Action Plans are based on investigation findings. Action items should address: - System weaknesses that are most directly associated with the event. - Steps in the process that are susceptible to failure or breakdown.

Hierarchy of Corrective Actions

Weaker Impact Intermediate Impact Stronger Impact Training / education Workload or staffing changes Engineering controls Change of a form (^) Reduction of interruptions and / or distractions Physical and / or structural changes to the environment Utilization of a label Checklists Standardization and hardwiring of a process Additional study Cognitive aids Cultural change New procedures Doublebacks -checks and / or read- Software changes Redundancy (^) Simplification of the process (reduce or change number of Communication structure^ steps)

Effectiveness of Error-Prevention Strategies

1. Design process for minimum error: “ Mistake-Proof ” it.
2. Control errors with active safety devices.
3. Provide warning devices for manual actions.
4. Use procedures for reduction of error and control.
5. Use administrative controls for reduction of error.
6. Rely on knowledge and skill of staff.

Most Effective

Least Effective

Type of SERIOUS SAFETY EVENT: List the Latent Weaknesses that contributed to the event (Inappropriate acts; system failures; equipment/deviceissues; etc.):

State the Root Cause(s):

List Corrective Action(s) for each Root Cause and Contributing Factor: # Corrective Actions Person(s) Responsible Due Date