Society of University SurgeonsCan simulation improve the traditional method of root cause analysis: A preliminary investigation
Section snippets
Methods
To select a case for direct RCA methodology comparison, all adverse events that required RCA investigation during the previous year (September 2010 to September 2011) at a major urban tertiary care hospital in New Orleans, LA (Tulane University Hospital) were reviewed by a multidisciplinary team of accreditation managers, surgical staff, and hospital legal staff. Adverse events were categorized by use of the major causal categories of the Eindhoven Classification Model (ECM; Table I), according
Results
A total of 165 person-hours were used in the development of this simulation series. This included the initial review of all RCAs at Tulane University Hospital from September 2010 to September 2011 (22 person-hours), the in-depth review for final event selection (13 person-hours), the development of the simulation series (27 person-hours), and performance of the simulations (103 person-hours). The person-hours per phase are shown in Table III. The in-depth review of the cases (to select the
Discussion
This study demonstrates that health care simulation-based RCA augments the effectiveness of nontechnical error analysis, elucidating root causes more amenable to effective intervention than traditional RCA methods. Root cause analysis has become the standard in the health care industry for evaluating serious adverse outcomes, so any techniques for improving its efficacy are critical to foster. If serious adverse outcomes are to be prevented in health care, then the personnel performing the
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Using Simulation to Improve Systems-Based Practices
2017, Joint Commission Journal on Quality and Patient SafetyCitation Excerpt :Evaluation of the entire system and the interaction of the individual with the system may help identify systems-based conditions that can be missed in the memory-based, retrospective review so commonly used in health care RCAs. In an attempt to address the limitations of retrospective RCAs, researchers at Tulane University School of Medicine have developed and assessed the feasibility of simulation of adverse outcomes (SAO) for adverse surgical events.40–42 In one study,40 this group examined 631 closed claims of a major medical malpractice insurance company and used simulation to create all aspects of three scenarios, including electronic health records, team composition, scripts, and other paperwork.
The Past, Present, and Future of Simulation-based Education for Pediatric Emergency Medicine
2016, Clinical Pediatric Emergency MedicineCitation Excerpt :Traditionally, this is done by simulating rare but important outcomes and through trialing new procedures and equipment with task trainers. Recently, simulations have focused more intentionally on patient safety through the use of simulated patient care handoffs, assessing adherence to care bundles, simulation-informed root cause analysis, and in situ simulation to identify latent patient safety threats.48–51 Traditionally, simulation has been available exclusively to large medical and academic centers due to the high cost and expertise required to use SBE.
Using Simulation to Improve Systems
2015, Surgical Clinics of North AmericaCitation Excerpt :Particular to trainees, patient hand-offs and technical competency, when supervised with appropriate leadership and reinforced over time, show promise for low-stakes, high-value systematic improvement.22 The use of simulated scenarios and the TeamSTEPPS philosophy has also been successfully applied to root cause analysis (RCA) of adverse events within the operating room.23,24 Before simulation, RCA at this institution was done retrospectively and with a bias toward identifying errors made by individuals rather than systemic error, correction of which holds far greater promise for improving quality, safety, and cost.
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Supported by a grant from The Doctors Company Foundation.