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Root Cause Analysis
Konrad C. Nau, MDProfessor and Chair
WVU Dept Family Medicine-Eastern Division
Objectives
1) Understand importance of systems-based thinking when adverse events occur in medicine
2) Learn three approaches to Root Cause Analysis
3) Understand common pitfalls encountered when approaching patient safety issues
What is Root Cause Analysis?
Process for identifying contributing/ causal factors that underlie variations in performance associated with adverse events or near-miss/close calls
Process that features interdisciplinary involvement of those closest to and/or most knowledgeable about the situation
Adverse and Sentinel Events “Unintended injury
to patients resulting from a medical intervention, which includes any action by healthcare workers, including clerical and maintenance staff.” Institute of Medicine
“An unexpected occurrence involving death or serious physical or psychological injury or risk thereof.” Joint Commission
Near-Miss Events
When two planes nearly collide, they call it a “near miss.” It’s a NEAR HIT.
A collision is a “near miss.” BOOM! “Look, they nearly missed!” George Carlin
The Absurd Way We Use Language
<www.georgecarlin.com>
Where Did it Come From?
Derivative of Failure Mode Effect Analysis (FMEA) – US Military(1949) to determine effect of system and equipment engineering failures
FMEA use by NASA for Apollo space program (1960s)
US Auto Industry FMEA Standards implemented (1993)
Why involve residents in RCA?
Residents know what happens at the microprocess level Residents are future leaders in healthcare Residents are either team members or as implementer
of key action plans Resident/Fellow Participation in Patient Safety Activities
- Baseline Analysis of National RCA database (many caveats)
Residents as RCA team members < 30 (< 0.1%) All physicians ~ 15%!
[email protected] www.patientsafety.gov
Overview of RCA Steps Charter an inter-disciplinary team (4-6 people)
Those familiar and un-familiar with the process Flow diagram of “what happened?”
Triggering questions to expand this view Site visits and simulation to augment Interviews with those involved or those with similar
job Resources (articles - NPSF, online databases) Root cause/contributing factors developed
Five rules of causation to guide/push the team deep enough
Cause and Effect Diagram, etc
Five Causal Rules - Marx Rule 1 - Causal Statements must
clearly show the "cause and effect" relationship. When describing why an event has
occurred, you should show the link between your root cause and the bad outcome
each link should be clear to the RCA Team and others.
Five Causal Rules - Marx Rule 2 - Negative descriptors (e.g.,
poorly, inadequate) are not used in causal statement To force clear cause and effect descriptions
(and avoid inflammatory statements), we recommend against the use of any negative descriptor that is merely the placeholder for a more accurate, clear description
“The Resident Manual was poorly written” vs “OnCall start and stop times are not documented
in policy”
Five Causal Rules - Marx Rule 3 - Each human error
must have a preceding cause. It is the cause of the error, not the
error itself, which leads us to productive prevention strategies.
“Joe ordered heparin and the patient bled out” vs
“Joe order heparin because he was unaware of a history of active Peptic Ulcer Disease in the pt.”
Five Causal Rules - Marx
Rule 4 - Each procedural deviation must have a preceding cause. Procedural violations are like errors in
that they are not directly manageable. Instead, it is the cause of the procedural violation that we can manage.
Five Causal Rules - Marx Rule 5 - Failure to act is only
causal when there was a pre-existing duty to act. A doctor's failure to prescribe a
medication can only be causal if he was required to prescribe the medication in the first place.
The duty to perform may arise from standards and guidelines for practice; or other duties to provide patient care.
NCPS RCA Model A rigorous,legally protected and confidential
approach to answering:
- What happened? (event or close call)What happened that day? What usually happens? (norms)What should have happened? (policies)
- Why did it happen? - What are we going to do to prevent it from happening again? (actions/outcomes)
- How will we know that our actions improved patient safety? (measures/tracking)
Methods of RCA
Questioning to the Void Event & Causal Factor
Analysis Safeguard Analysis
Questioning to the Void
A systematic approach of asking questions: How is it that? What do we know about . . .?
In Japan, called the Five Whys.
Questioning to the Void Toyota says ask why 5 times Keep going until your answer to why
is: I don’t know I don’t care
It fell because of gravity. Why is there gravity? (I don’t care)
Event & Causal Factor Analysis
Work order written forOxygen
MaintenanceShuts offoxygen
Staff reportsPatients are
Gasping.
Valves not Labeled
Staff thinksoxygen cut
off
Wrong Valve Closed
Staff not briefed
The Bidirectional RCA Process
Work backward chronologically from event to see what happened
Work forward chronologically to clarify and learn (Paradies)
Cause and effect are same thing
Gano
Effects “caused by”
Causes
1. Injury Fall
2. Fall Wet surface
3. Wet surface
Leaky valve
4. Leaky valve
Seal failure
5. Seal failure
Not maintained
1 2 3 4 5 A continuum of causes
Safeguard Analysis
SOURCE VICTIM
SAFEGUARDS
Steps in Safeguard Analysis Identify potential or actual source
of an event and identify the actual or potential victim.
Identify safeguards currently in place and determine effectiveness.
Develop plan to strengthen weak safeguards.
Identify/deploy new safeguards.