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• The Problem with Root cause analysis
  Siti Hosier
  Published on: 14 September 2016

• Published on: 14 September 2016

  The Problem with Root cause analysis

  • Siti Hosier
  • Other Contributors:
    • UPWEY

  I read with interest the article by Peerally et al (1) on 'The problem with root cause analysis'. I reflected on the recent cases that happened at Royal North Shore Hospital and Sydney Hospital (2,3,4) which led me to consider which investigative tool is best applied to different incidences and identified risks. The use of appropriate tools and involvement of key stakeholders are crucial elements to a successful investig...

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  I read with interest the article by Peerally et al (1) on 'The problem with root cause analysis'. I reflected on the recent cases that happened at Royal North Shore Hospital and Sydney Hospital (2,3,4) which led me to consider which investigative tool is best applied to different incidences and identified risks. The use of appropriate tools and involvement of key stakeholders are crucial elements to a successful investigative process and outcomes, however, we cannot ignore the reality of the process cost versus event severity and risk. Use of tools by subject matter expert Root cause analysis (RCA) is a tool used in many investigative incidences (5,6). Often as a result recommendations are made yet similar errors still happen. As correctly mentioned by Peerally et al, most investigations of incidences are done by the local team involved with RCA tools but with a lack of expert accident investigator involvement to ensure regular feedback loops and ongoing corrective actions. I do agree that hospitals should move toward proactively preventing adverse incidences for high probability, high severity risks. Preventing adverse incidences can eliminate harm to patients, reduce liability for organisations and reduce both operating costs and the need for resources. A proactive approach often uses Failure Mode Effect Analysis (FMEA) tools. FMEA often requires a higher level of investigative expertise and as such often costs more so it may be optimal to assess risks on a probability severity matrix to identify which tools are optimal. The proposal of engaging an independent professional body, while preferable, can be time-consuming and expensive. I propose for most cases (with exception for cases with significant legal liability) this level of expertise and independence could be developed within the organisation. The body i.e. quality or risk management department, should comprise of people with qualifications such as system thinking, sound interviewing techniques, able to involve staff, human factor analysis, current clinical practice, health management and have the ability to analyse data (7). This department could then act as a quasi-independent body to avoid situational bias and provide a platform for disseminating the results to intra- hospitals, inter-hospitals and governmental bodies as shared learning to help prevent occurrence or recurrence. As a largely independent department within the organisation, they can for most cases facilitate the investigative processes objectively thus eliminating tendency to blame (8,9,10). Key stake holders' involvement The involvement of key stakeholders is very crucial in any investigative process; leaders, managers, clinicians. The leaders provide governance, leadership and support to the managers. They are involved in the investigative process to gain their input, consensus and to commit resources for any recommendations that might be made. It is critical leaders set departmental performance indicators with due acknowledgment for the resources needed to achieve them as too often the burden of performance and blame is levied on departments, middle management and individuals where identified risk avoidance is under- resourced. The managers (department managers, quality and risk managers) are required to provide a safe environment for practice. They are to ensure that the protocols and standards of care are adhered to and patients are managed in a consistent manner. The role of the manager also includes identifying risks and establish processes to prevent the risks from reaching the patient with the support from the leader. The clinicians are required to conduct the procedures/practices in compliance with their scope of practice, organisational and regulatory boards. Conclusion The usage of an appropriate tool by a qualified person with the right expertise makes a difference. It would be economically unrealistic to apply full FMEA processes for every incident or identified risk profile, so the establishment of an organisational risk severity/probability matrix needs to be developed so the most appropriate tool is used. The involvement of key people ensures that a holistic approach is applied and outcomes of the investigations are implemented with feedback checks and balances and shared across intra-departments, inter-hospitals and at national level (11).

  References: 1)Peerally MF, Carr S, Waring J, Dixon-Woods M. The problem with root cause analysis. BMJ Qual Saf. 2016 Aug;1:1-6 2)Bodies swapped: Dead baby mistakenly cremated and daughter finds mother's body mislabelled at Royal North Shore Hospital [television broadcast]. Sydney: The Sydney Morning Herald; 2016 Aug 31. Available from: www.smh.com.au/nsw/daughter-finds-mothers-body-mislabelled-in-morgue -mixup-at-royal-north-shore-hospital-20160830-gr4g3n.html 3)Joseph AP, Hunyor SN. The Royal North Shore Hospital inquiry: a analysis of the recommendations and the implications for quality and safety in Australian public hospitals. Med J Aust. 2008 April ;188(8):469-72 4)Family want justice for fatal gas mix up [television broadcast]. Sydney: Skynews; 2016 Jul 26. Available from: http://www.skynews.com.au/news/top- stories/2016/07/26/incorrect-gas-fitting-behind-nsw-baby-death.html 5)Clifford SP, Mick PB, Derhake, BM. A Case of Transfusion Error in a Trauma Patient with Subsequent Root Cause Analysis Leading to Instituitional Change. J Investig High Impact Case Rep. 2016 May; 4(2):1-4 6)Van-Galen LS, Struik PW, Driesen BEJM, Merten H, Ludikhuize J, Van der Spoel JI, Kramer MHH, Nanayakkara PWB. Delayed Recognition of Deterioration of Patients in General Wards Is Mostly Caused by Human Related Monitoring Failures: A Root Cause Analysis of Unplanned ICU Admissions. 2016 Aug; 11(8):1-14 7) Ibrahim JE. What is the quality of our quality managers? Is it time for quality managers in Australia to be certified? J.Qual Clin Practice. 2000;20(1):32 8)Smetzer JL, Cohen MR. Lessons from the Denver medication error/criminal negligence case: look beyond blaming individuals. Hosp Pharm. 1998;33:640- 57. 9)Leape L. Error in medicine. JAMA. 1994;272:1851-7 10)Runciman W, Merry A, Smith AM. Improving patients' safety by gathering information. Anonymous reporting has an important role. BMJ. 2001;323:7308 11)Leape LL. Why should we report adverse incidents? J Eval Clin Pract. 1999;5:1-4

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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