SafetyInsights.org

Here’s another study exploring the effectiveness of root cause investigations (in healthcare).

After a systematic search, 21 articles met inclusion for analysis. 9 articles were assessed as moderate quality, 5 considerable quality and 7 as high quality.

Key findings:

·        “It is not clear if root cause analysis is effective in preventing the recurrence of adverse events”

·        “RCA is a useful tool for the identification of the remote and immediate causes of safety incidents, but not for implementing effective measures to prevent their recurrence”

·        “Only in 2 studies (9%) could it be established that RCAs contributed to the improvement of patient care to some extent”

·        “In 10 (50%) of them, the recommendations made were weak, which did not lead to a reduction of AEs”

·        “Some studies warned that sometimes poorly designed action plans and measures may generate new risks and may be insufficient to prevent the occurrence of new events”

·        “it was found that 72% of the recommendations categorised as relevant were not formulated and that the most common recommendations did not refer to latent causes in clinical practices but to active errors”

·        “Likewise, other studies [3, 6] stated that most of the proposed recommendations focused on active errors and neglected latent causes, which provides short-term solutions but only partially helps to avoid future incidents”

·        “1 study (5%) did demonstrate the usefulness of RCA and its recommendations”

·        “Although some studies have demonstrated the usefulness of RCA and its recommendations [24], most published studies found that just over half of the recommendations that resulted from RCA were not useful enough to prevent the same incidents from recurring in the future”

They conclude that “It seems, therefore, that RCA is a process with considerable validity through which much may be learned about incidents [12, 15]. However, it does not seem to produce enough benefits to address and resolve the problem [23, 25] and, thus, to avoid possible AAEs”.

And

“Although early studies suggested that RCAs are effective in promoting ideas for preventing recurrence, more recent studies do not confirm these findings”.

Ref: Martin-Delgado, J., Martínez-García, A., Aranaz, J. M., Valencia-Martín, J. L., & Mira, J. J. (2020). How much of root cause analysis translates into improved patient safety: a systematic review. Medical Principles and Practice, 29(6), 524-531.

Study link: https://karger.com/mpp/article-pdf/29/6/524/3128116/000508677.pdf

My site with more reviews: https://safety177496371.wordpress.com

LinkedIn post: https://www.linkedin.com/posts/benhutchinson2_heres-another-study-exploring-the-effectiveness-activity-7223794459736428544-6P3K?utm_source=share&utm_medium=member_desktop