Elsevier

Surgery

Volume 152, Issue 3, September 2012, Pages 489-497
Surgery

Society of University Surgeons
Can simulation improve the traditional method of root cause analysis: A preliminary investigation

https://doi.org/10.1016/j.surg.2012.07.029Get rights and content

Introduction

The Joint Commission on Accreditation of Healthcare Organizations recommendations for conducting root cause analysis (RCA) include identifying “root causes” and “common-cause variation” rather than “proximate causes” and “special-cause variation” to create interventions. Simulation for health care RCA is a novel technique but has not been compared with traditional RCA methods.

Methods

All of the RCAs of adverse events conducted at Tulane Hospital between September 2010 and September 2011 were reviewed. A case of missed postprocedural, preoperative hemorrhage resulting in death was chosen. Hospital records were analyzed to identify the presumed root causes. A simulation of the event was developed and conducted. Six test subjects (preoperative and postanesthesia care unit nurses) participated in the simulation. Root causes identified by simulation analysis were compared with those identified by traditional RCA.

Results

In 2 of 6 simulations, the adverse event was duplicated. The root cause identified by standard RCA technique was inattention to signs of bleeding in the patient/ lack of appropriate monitoring of the patient by nursing staff (“special-cause variation”). Simulation-based RCA revealed that the root cause was not only inadequate monitoring, but also the lack of physical presence of physicians in the care environment (“common-cause variation”). Simulation-based RCA identified root causes more amenable to intervention.

Discussion

This study demonstrates that simulation-based RCA can identify additional root causes amenable to making health care interventions when compared with traditional RCA.

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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Supported by a grant from The Doctors Company Foundation.

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