How Much of Root Cause Analysis Translates into Improved Patient Safety: A Systematic Review.

OBJECTIVES: The aim of this systematic review was to consolidate studies to determine whether root cause analysis (RCA) is an adequate method to decrease recurrence of avoidable adverse events (AAEs). METHODS: A systematic search of databases from creation until December 2018 was performed using PubMed, Scopus and EMBASE. We included articles published in scientific journals describing the practical usefulness in and impact of RCA on the reduction of AAEs and whether professionals consider it feasible. The Mixed Methods Appraisal Tool was used to assess the quality of studies. RESULTS: Twenty-one articles met the inclusion criteria. Samples included in these studies ranged from 20 to 1,707 analyses of RCAs, AAEs, recommendations, audits or interviews with professionals. The most common setting was hospitals (86%; n = 18), and the type of incident most analysed was AAEs, in 71% (n = 15) of the cases; 47% (n = 10) of the studies stated that the main weakness of RCA is its recommendations. The most common causes involved in the occurrence of AEs were communication problems among professionals, human error and faults in the organisation of the health care process. Despite the widespread implementation of RCA in the past decades, only 2 studies could to some extent establish an improvement in patient safety due to RCAs. CONCLUSIONS: RCA is a useful tool for the identification of the remote and immediate causes of safety incidents, but not for implementing effective measures to prevent their recurrence.

Root cause analysis in the NHS: time for change?

Root cause analyses were intended to search for system vulnerabilities rather than individual errors, using a human factors engineering approach. In practice, root cause analyses done in the NHS may generally fail to identify components where there are organisational failures, as there may be an inherent desire to protect institutional reputation. A human factors approach to root cause analysis looks at system vulnerabilities, considering the entirety of the environment in which an individual works and taking into account factors such as the physical environment and individual mental characteristics. Other human factors include group dynamics, task complexity and concurrent tasks. It is time that the growing evidence of the potential shortcomings of root cause analysis, especially as frequently applied within the NHS, is heeded. At present, rather than assisting learning it may be an impediment to patient safety. The authors propose that root cause analyses should be performed by a group of people who are not managing the service. External organisations such as the General Medical Council, Nursing and Midwifery Council, Care Quality Commission and Practitioner Performance Assessment are heavily reliant on this tool when concerns are raised. If the flaws in root cause analysis can be eliminated, drawing on the available evidence, cases such as those of Dr Hadiza Bawa-Garba and Mr David Sellu might be avoided.

[Critical Incident Reporting System in Risk Management at the Eye Center in Freiburg]. / Das Critical Incident Reporting System im Risikomanagement der Klinik für Augenheilkunde in Freiburg.

Background With the help of reporting systems, errors that occur in medical settings can be documented and can lead to an improved workflow. We, herein, present data from our reporting system that we have used since 2012. Materials and Methods All reports since 2012 were evaluated and analyzed regarding the annual rate of reportings, who reported and what reasons were suspected to be causative for the reported errors. Results Over the last five years a mean of 33 reports were given annually. While mostly doctors reported in the first year, the following years showed almost balanced reports from medical assistant staff and doctors. Not all of these reports resulted in actions. The most often stated reason for errors or critical situations was miscommunication between the staff. Conclusion Our data show that a constant number of reports can be obtained over at least five years from doctors as well as medical assistant staff. The main reason for critical situations seems to be miscommunication. With the increased experience with reporting systems, such as CIRS, we can expect more comparative data.

Embedding learning from adverse incidents: a UK case study.

Purpose This paper reports on a regionally based UK study uncovering what has worked well in learning from adverse incidents in hospitals. The purpose of this paper is to review the incident investigation methodology used in identifying strengths or weaknesses and explore the use of a database as a tool to embed learning. Design/methodology/approach Documentary examination was conducted of all adverse incidents reported between 1 June 2011 and 30 June 2012 by three UK National Health Service hospitals. One root cause analysis report per adverse incident for each individual hospital was sent to an advisory group for a review. Using terms of reference supplied, the advisory group feedback was analysed using an inductive thematic approach. The emergent themes led to the generation of questions which informed seven in-depth semi-structured interviews. Findings "Time" and "work pressures" were identified as barriers to using adverse incident investigations as tools for quality enhancement. Methodologically, a weakness in approach was that no criteria influenced the techniques which were used in investigating adverse incidents. Regarding the sharing of learning, the use of a database as a tool to embed learning across the region was not supported. Practical implications Softer intelligence from adverse incident investigations could be usefully shared between hospitals through a regional forum. Originality/value The use of a database as a tool to facilitate the sharing of learning from adverse incidents across the health economy is not supported.

Root cause analyses performed in a children's hospital: events, action plan strength, and implementation rates.

This study describes the types of events leading to the performance of root cause analyses (RCA) and the implementation rate and quality of the action plans developed for RCAs performed at a free standing children's hospital. Twenty serious adverse events resulting in RCAs took place between January 2007 and June 2009. A wide variety of events triggered RCAs however, 30% involved medication errors. Seventy-eight action plans were developed with an average of 3.9 ± 1.3 per RCA. Action plans were classified as weaker 46% of the time, intermediate 44% of the time, and stronger 10% of the time. Intermediate or stronger action plans were developed to address 90% of the events. Ninety-five percent of the action plans were implemented. This study demonstrates that RCA can be effectively utilized to consistently generate moderate and high impact action plans to address a diverse array of adverse events within a children's hospital. Near complete implementation of action plans can be achieved.