I came across this healthcare research paper touting the value of using Root Cause Analysis (RCA) to improve patient safety, with an emphasis on LATENT ORGANIZATIONAL factors that play a role in accidents. There were so many incredible tidbits in the paper that I have summarized them below. Many of you reading this are NOT in healthcare, but this paper explains the benefits of using an RCA in any environment. Just switch the word “patient” with “employee,” and we have a perfect fit for our workplaces.
Note: the emphasis is by me; you will notice a lot of language from James Reason’s work
Root Cause Analysis (RCA) is a structured method to analyze serious adverse events. A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals. RCA thus uses the systems approach to identify both ACTIVE errors (errors occurring at the point of interface between humans and a complex system) and LATENT ORGANIZATIONAL errors (the hidden problems within systems that contribute to adverse events). It is one of the most widely used retrospective methods for detecting safety hazards.
RCAs should generally follow a pre-specified protocol that begins with data collection and reconstruction of the event in question through record review and participant interviews. A multidisciplinary team should then analyze the sequence of events leading to the error, with the goals of identifying how the event occurred (through identification of ACTIVE errors) and why the event occurred (through systematic identification and analysis of LATENT ORGANIZATIONAL).
The ultimate goal of RCA is to prevent future harm by eliminating the LATENT ORGANIZATIONAL errors that so often underlie incidents.
| Factors That May Lead to LATENT ORGANIZATIONAL Errors | |
| Type of Factor |
Example |
|
Institutional/regulatory |
A patient on anticoagulants received an intramuscular pneumococcal vaccination, resulting in a hematoma and prolonged hospitalization. The hospital was under regulatory pressure to improve its pneumococcal vaccination rates. |
|
Organizational/management |
A nurse detected a medication error, but the physician discouraged her from reporting it. |
| Work environment |
Lacking the appropriate equipment to perform hysteroscopy, operating room staff improvised using equipment from other sets. During the procedure, the patient suffered an air embolism. |
| Team environment |
A surgeon completed an operation despite being informed by a nurse and the anesthesiologist that the suction catheter tip was missing. The tip was subsequently found inside the patient, requiring reoperation. |
| Staffing |
An overworked nurse mistakenly administered insulin instead of an antinausea medication, resulting in a hypoglycemic coma. |
| Task-related |
An intern incorrectly calculated the equivalent dose of long-acting MS Contin for a Vicodin patient. The patient experienced an opiate overdose and aspiration pneumonia, resulting in a prolonged ICU course. |
| Patient characteristics |
The parents of a young boy misread the instructions on a bottle of acetaminophen, causing their child to experience liver damage. |
RCA is a widely used term, but many find it misleading. As illustrated by the [James Reason’s] Swiss Cheese Model, multiple errors and system flaws often must intersect for a critical incident to reach the patient. Labeling one or several of these factors as “causes” may emphasize specific “holes in the cheese” and obscure the relationships between different layers and other aspects of system design. Accordingly, some have suggested replacing the term “root cause analysis” with “systems analysis.”
Effectiveness of a Root Cause Analysis
Root cause analysis is one of the most widely used approaches to improving safety, but its effectiveness has been questioned. Studies have shown that RCAs often fail to result in the implementation of sustainable systems-level solutions. A 2017 commentary identified eight (8) common reasons for the ineffectiveness of the RCA process, including:
- overreliance on weak solutions (such as educational interventions and enforcing existing policies),
- failure to aggregate data across institutions, and
- failure to incorporate human factors engineering and safety science principles into error analysis and improvement efforts
The National Patient Safety Foundation has proposed renaming the process root cause analysis and action (RCA2)—emphasizing that a well-done RCA should yield robust CORRECTIVE ACTIONS and RISK REDUCTION.
As detailed in a 2016 Annual Perspective, safety experts agree that EFFECTIVE ERROR ANALYSIS requires:
- the active involvement of organizational leadership,
- training of specialized teams with expertise in safety science, focusing on stronger systems-level solutions, and
- measuring implementation and impact on outcomes
Given the considerable time investment required to perform a formal RCA, more abbreviated incident analysis techniques may be appropriate in some cases.
