Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the gap

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Abstract

This paper examines the challenges of investigating clinical incidents through the use of Root Cause Analysis. We conducted an 18-month ethnographic study in two large acute NHS hospitals in the UK and documented the process of incident investigation, reporting, and translation of the results into practice. We found that the approach has both strengths and problems. The latter stem, in part, from contradictions between potentially incompatible organizational agendas and social logics that drive the use of this approach. While Root Cause Analysis was originally conceived as an organisational learning technique, it is also used as a governance tool and a way to re-establish organisational legitimacy in the aftermath of incidents. The presence of such diverse and partially contradictory aims creates tensions with the result that efforts are at times diverted from the aim of producing sustainable change and improvement. We suggest that a failure to understand these inner contradictions, together with unreflective policy interventions, may produce counterintuitive negative effects which hamper, instead of further, the cause of patient safety.

Introduction

In line with the global patient safety agenda, an increasing number of healthcare institutions have adopted structured investigation processes as a way of learning from clinical incidents. This approach to organisational learning is based on the assumption that through determining the underlying causes of adverse events and drawing the necessary lessons, it is possible to prevent their reoccurrence (Donaldson, 2000). A common way to investigate clinical incidents is through Root Cause Analysis (RCA), a methodology combining elements from engineering, psychology, and the ‘human factors’ tradition (Reason, 1990, Vincent et al., 1998). As indicated by its name, RCA directs analytical attention to the root or latent factors that condition, enable or exacerbate clinical risk with the aim of producing recommendations on how these underlying causes should be managed or eradicated (Carroll, Rudolph, & Hatakenaka, 2002).

While RCA is formally endorsed by policy makers in USA, UK, Australia, and Denmark (Øvretveit, 2005) and is in the process of being adopted by other countries, we have only a partial understanding of the challenges of using this approach, despite research suggesting it is not without problems (Braithwaite et al., 2006, Iedema, Jorm, Braithwaite et al., 2006, Iedema, Jorm, Long et al., 2006, Wallace, 2006, Wu et al., 2008). Building on an extensive 12-month ethnographic study within two large acute hospitals in the UK National Health Service (NHS), we examine how the investigation of clinical incidents is conducted in practice. Our main aim is to determine the challenges of using the RCA approach and to understand where such challenges originate. Our main finding is that the problems observed stem from an inherent tension that derives from RCA being conceived not only as an improvement technique but also as a governance tool. We argue that the approach, which originally responded to a logic of learning, empowerment and decentralisation, is often translated into practice as a bureaucratic mode of legitimation and governance. Although these principles often co-exist, at times they diverge so that the effort is averted from producing organisational learning. We argue that a better understanding of these tensions may help introduce corrective actions which may lead to a better use of this particular approach to improve patient safety.

Section snippets

Root cause analysis in healthcare

RCA is the umbrella term describing methodologies and tools for the retrospective and structured investigation of adverse incidents, near misses and sentinel events (Wald and Shojania, 2001). Originally developed to analyse major industrial incidents (Andersen and Fagerhaug, 2000, Carroll, 1998), since the mid-1990s it has been taken up in healthcare systems, such as the US (Bagian et al., 2002, Wu et al., 2008), Australia, and the UK (Øvretveit, 2005, NPSA, 2004). Although each country (indeed

The study

Our paper draws on an 18-month ethnographic study within two acute hospitals (Trusts) in the UK NHS, conducted between 2008 and 2009. These Trusts were selected to reflect variability and difference in terms of size, research and teaching commitments and regional location. Site A was a medium-sized secondary care provider based primarily on one site, with 6000 staff and treating 500,000 patients a year. Site B was a large teaching Trust located over three sites providing a wide range of

Collecting information

The first major challenge of undertaking RCA investigations related to the collection of information and evidence. After a reported incident had been graded and designated for investigation, the RCA lead – whether corporate manager or local Patient Safety Lead – was responsible for gathering more detailed information to first, substantiate the contents of the report and second, to gather evidence about the actions and events leading up to the event. This usually involved: requesting patient

Discussion

Our study adds to a growing body of research on the challenges of using RCA (Braithwaite et al., 2006, Tamuz et al., 2011, Wu et al., 2008). We find that in practice difficulties arise at several stages of the RCA process. The question therefore is where do these challenges originate? Interrogating the nature and origins of these challenges has relevant practical and theoretical implications for patient safety. Our observations indicate that some of the challenges derive not so much from a

Concluding remarks

Our paper argues that the gap between theory and practice in RCA investigations can be explained through recognising the distinct policy agendas through which RCA has been translated. These serve to partially displace the espoused goal of preventing the reoccurrence of patient safety incidents through organizational learning. While the current model of RCA is clearly a significant improvement on previous approaches to learning, it might still be argued that it does not fulfil its potential and

Acknowledgements

The paper builds on the results of the project Improving the Capacity of Healthcare Organisations to Act on Evidence in Patient Safety (PTOC21) funded by the Warwick International Manufacturing Research Centre. The WIMRC is supported by the UK EPSRC with supplementary contributions from collaborating partners The research team also included Prof. Jacky Swan and Prof. Peter Spurgeon. Their invaluable contribution is gratefully acknowledged.

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