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Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?
  1. Kathryn M Kellogg1,
  2. Zach Hettinger1,
  3. Manish Shah2,
  4. Robert L Wears3,
  5. Craig R Sellers4,
  6. Melissa Squires5,
  7. Rollin J Fairbanks1
  1. 1MedStar Health, MedStar Institute for Innovation, Washington District of Columbia, USA
  2. 2BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, USA
  3. 3Department of Emergency Medicine/CSRU, University of Florida/Imperial College London, Jacksonville, Florida, USA
  4. 4University of Rochester School of Nursing, Rochester, New York, USA
  5. 5Nationwide Children's Hospital, Columbus, Ohio, USA
  1. Correspondence to Dr Kathryn M Kellogg, MedStar Health, MedStar Institute for Innovation, Washington, DC 20008, USA; kate.kellogg{at}


Background Despite over a decade of efforts to reduce the adverse event rate in healthcare, the rate has remained relatively unchanged. Root cause analysis (RCA) is a process used by hospitals in an attempt to reduce adverse event rates; however, the outputs of this process have not been well studied in healthcare. This study aimed to examine the types of solutions proposed in RCAs over an 8-year period at a major academic medical institution.

Methods All state-reportable adverse events were gathered, and those for which an RCA was performed were analysed. A consensus rating process was used to determine a severity rating for each case. A qualitative approach was used to categorise the types of solutions proposed by the RCA team in each case and descriptive statistics were calculated.

Results 302 RCAs were reviewed. The most common event types involved a procedure complication, followed by cardiopulmonary arrest, neurological deficit and retained foreign body. In 106 RCAs, solutions were proposed. A large proportion (38.7%) of RCAs with solutions proposed involved a patient death. Of the 731 proposed solutions, the most common solution types were training (20%), process change (19.6%) and policy reinforcement (15.2%). We found that multiple event types were repeated in the study period, despite repeated RCAs. This study found that the most commonly proposed solutions were weaker actions, which were less likely to decrease event recurrence. These findings support recent attempts to improve the RCA process and to develop guidance for the creation of effective and sustainable solutions to be used by RCA teams.

  • Root cause analysis
  • Significant event analysis, critical incident review
  • Medical error, measurement/epidemiology

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  • Funding This study was funded by the ‘Year-Out Research Fellowship’ grant from the University of Rochester School of Medicine and Dentistry and by the Emergency Medicine Patient Safety Foundation. At the time of this study, RF was supported by a Career Development Award from the NIBIB, K08EB009090.

  • Competing interests None declared.

  • Ethics approval University of Rochester School of Medicine and Dentistry.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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