RT Journal Article
SR Electronic
T1 Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?
JF BMJ Quality & Safety
JO BMJ Qual Saf
FD BMJ Publishing Group Ltd
SP 381
OP 387
DO 10.1136/bmjqs-2016-005991
VO 26
IS 5
A1 Kathryn M Kellogg
A1 Zach Hettinger
A1 Manish Shah
A1 Robert L Wears
A1 Craig R Sellers
A1 Melissa Squires
A1 Rollin J Fairbanks
YR 2017
UL http://qualitysafety.bmj.com/content/26/5/381.abstract
AB 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.Conclusions 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.