SafetyInsights.org

This is a healthcare study which analysed root cause analysis (RCA) investigation reports over an 8-year period from a major academic institution. 302 RCAs were included and the main goal was to assess the types of solutions proposed in the reports to prevent reoccurrence of the events.

It’s stated that despite intensified efforts towards increasing safety within healthcare, the rate of adverse events has essentially remained the same.

Results:

Of the analysis of RCA reports, found was that the most common solutions were: training at 20%, process change at 19.6% and policy reinforcement at 15.2%. That is, the “most commonly proposed solutions were weaker actions, which were less likely to decrease event recurrence” (p381).

Expanding on the most common solutions, training, the most frequent solution, was often proposed via didactic teaching (where focus is on the instructor providing information and instructees are mostly passive listening), faculty/staff discussions or via in-service training.

Process change was the second most common, which could involve a process change (change in workflow) or procedures around communication. For instance, following an incorrect surgical count (which didn’t identify a surgical sponge), the proposed process change, which seemed quite empty & lacking nuance for something so important, was to change communication by calling for the surgeon & radiologist to “collaborate with regard to the plan for imaging the area under review” (p384).

Finally, policy reinforcement was the third most proposed solution – where RCAs would propose for people to be reminded of procedures in use. Authors suggest that solutions such as reminding people to use the correct procedure is a good example of work as imagined. Here, they argue that “This violates the basic premise of safety engineering involving sociotechnical systems, which recognises that human errors will always be repeated [without redesigning the conditions that people work under]” (p385).

Overall, the authors argue that few of the solutions within the RCAs included deeper design changes to remove the hazards. Further, authors observed that despite multiple RCAs, the same event types repeatedly occurred in the sample period. Quoting the study, “While recognising that some types of events are impossible to eliminate completely, we propose that repeat events occur despite repeat RCAs because of the quality and types of solutions that are proposed by RCA teams” (p385).

In many of the cases, RCAs were found not to identify “meaningful aspects of the event but simply observes that humans are imperfect” (p385), such as reports highlighting people forgetting things taught to them (which, according to the authors, simply highlights that human memory is imperfect).

These types of findings are “…trivial and will not contribute to sustainable change without some kind of change in the work setting to support the cognitive work of the healthcare worker or reduce the burden of having to remember critical pieces of information” (p385).

Authors: Kathryn M Kellogg, Zach Hettinger, Manish Shah, Robert LWears, Craig R Sellers, Melissa Squires, Rollin J Fairbanks, 2008, BMJ Qual Saf

Study Link: http://dx.doi.org/10.1136/bmjqs-2016-005991

Link to the LinkedIn article: https://www.linkedin.com/pulse/our-current-approach-root-cause-analysis-contributing-ben-hutchinson