Question

Researchers now believe that most medical errors cannot be prevented by perfecting the technical work of individual doctors, nurses, or pharmacists. Improving patient safety often involves the coordinated efforts of multiple members of the health care team, who may adopt strategies from outside health care.”

“The report reviews several practices whose evidence came from the domains of commercial aviation, nuclear safety, and aerospace, and the disciplines of human factors, engineering and organizational theory. Such practices include root cause analysis, computerized physician order entry and decision support, auto-mated medication dispensing systems, bar coding technology, aviation-style preoperative checklists, promoting a ‘culture of safety,’ crew resource management, the use of simulators in training, and integrating human factors theory into the design of medical devices and alarms.

” Discuss this concept of utilizing standard business quality initiatives and the logic of adopting them to use in healthcare. Using the practice of Root cause analysis, research, summarize, and include how you might apply this concept in your healthcare facility

Answer 1

Serious adverse events continue to occur in clinical practice, despite best preventive efforts.In a culture of safety,underlying system contributors are identified so that measures can put in place to prevent a similar occurrence in the future,rather than blaming the most proximate individual.

Root cause analysis (RCA) is a process to identify factors that underlie variation in performance or that predispose an event toward undesired outcomes and allow for development of effective strategies to decrease the likelihood of similar adverse events occurring in the future.

The purpose of an RCA is to find out what happened,why it happened,and determine what changes needed to be made.An RCA consists of three fundamental components

• Consideration and identification of factors most directly associated with the adverse event
• Analysis and prioritization of these factors to plan the introduction of effective strategies to prevent them from recurring
• Introduction,management,and wherever possible,dissemination of effective countermeasures that are shown to have a beneficial effect.

There are many challenges to undertaking root cause analysis in health care such as forming and leading the investigation team,gathering and analysing supporting evidence,and formulating and implementing service improvements.RCA remains a complex non- linear task which needs balancing a multiplicity of concerns and expectations.The aim of doing an RCA focus the instrumental aim of triggering sustainable service improvement and not for the investigation to become an end in itself.

Staff participation is very important in doing quality improvement practices. Creating awareness among the staff members, the health care leadership need to provide open endorsement of root cause analysis,with learning activities and new analytic tools and development capabilities in change management.Many tools are used for doing an RCA : 5 Whys,cause- and- effect,or Ishikawa diagrams,causal tree mapping,affinity diagrams,and Pareto charts(The 80-20 rule)

5 Whys of RCA: is simple and an iterative interrogative technique used to explore the cause- and- effect relationships underlying a particular problem.The primary goal of the technique is to determine the root cause of a defect or problem by repeating the question “ Why?”.Each answer forms the basis of the next question.

For an effective root cause analysis,it must include, determination of human and other factors.Determination of related processes and systems.Analysis of underlying causes and effect systems through series of WHY questions.As per Joint commission a credible RCA to be performed within 45 days for all sentinel or major adverse events.