Our current approach to root cause analysis: Is it contributing to our failure to improve patient safety?

BMJ Quality and Safety

Volumn 26, Issue 5, 2017, Pages 381-387

  Kellogg, Kathryn M ^a   Hettinger, Zach ^a   Shah, Manish ^b   Wears, Robert L ^c   Sellers, Craig R ^d   Squires, Melissa ^e   Fairbanks, Rollin J ^a  

^a MEDSTAR HEALTH RESEARCH INSTITUTE   (United States)

^b UNIVERSITY OF WISCONSIN SCHOOL OF MEDICINE AND PUBLIC HEALTH   (United States)

^c UNIVERSITY OF FLORIDA COLLEGE OF MEDICINE   (United States)

^d UNIVERSITY OF ROCHESTER SCHOOL OF NURSING   (United States)

^e NATIONWIDE CHILDREN S HOSPITAL   (United States)

Author keywords

Medical error measurement epidemiology; Root cause analysis; Significant event analysis, critical incident review

Indexed keywords

ADULT; ARTICLE; EMERGENCY PATIENT; FEMALE; FOLLOW UP; HEALTH CARE POLICY; HEALTH CARE QUALITY; HEALTH PROGRAM; HUMAN; MAJOR CLINICAL STUDY; MALE; MEDICAL RECORD; MIDDLE AGED; PATIENT SAFETY; QUALITATIVE ANALYSIS; QUALITATIVE RESEARCH; RISK MANAGEMENT; ROOT CAUSE ANALYSIS; TERTIARY CARE CENTER; TOTAL QUALITY MANAGEMENT; ACCREDITATION; FACTUAL DATABASE; MEDICAL ERROR; NEW YORK; POSTOPERATIVE COMPLICATION; PREVENTION AND CONTROL; SAFETY; STANDARDS; STATISTICS AND NUMERICAL DATA; UNITED STATES; UNIVERSITY HOSPITAL;

ACADEMIC MEDICAL CENTERS; DATABASES, FACTUAL; HUMANS; JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS; MEDICAL ERRORS; NEW YORK; PATIENT SAFETY; POSTOPERATIVE COMPLICATIONS; ROOT CAUSE ANALYSIS; SAFETY MANAGEMENT; UNITED STATES;

EID: 85018382418     PISSN: 20445415     EISSN: None     Source Type: Journal    
DOI: 10.1136/bmjqs-2016-005991     Document Type: Article

References (39)

1. Wachter RM. Patient safety at ten: Unmistakable progress, troubling gaps. Health Aff 2010;29:165-73.
2. Shekelle PG, Pronovost PJ, Wachter RM, et al. Advancing the science of patient safety. Ann Intern Med 2011;154:693-6.
3. Landrigan CP, Parry GJ, Bones CB, et al. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med 2010;363:2124-34.
4. Leape LL, Berwick DM. Five years after To Err Is Human: What have we learned JAMA 2005;293:2384-90. http://www.ncbi.nlm.nih.gov/entrez/query.fcgicmd=Retrieve&db=PubMed&dopt=Citation&list-uids=15900009.
5. Wachter RM. The end of the beginning: Patient safety five years after "To Err Is Human". Health Aff 2004;Suppl Web Exclusives:W4-534-545.
6. Brennan TA, Gawande A, Thomas E, et al. Accidental deaths, saved lives, and improved quality. N Engl J Med 2005;353:1405-9.
7. Longo DR, Hewett JE, Ge B, et al. The long road to patient safety: A status report on patient safety systems. JAMA 2005;294:2858-65.
8. Shojania KG, Thomas EJ. Trends in adverse events over time: Why are we not improving BMJ Qual Saf 2013;22:273-7.
9. Baines R, Langelaan M, de Bruijne M, et al. How effective are patient safety initiatives A retrospective patient record review study of changes to patient safety over time. BMJ Qual Saf 2015;24:561-71.
10. Austin JM, Andrea GD, Birkmeyer JD, et al. Safety in numbers: The development of leapfrog ' s composite patient safety score for U. S. Hospitals. J Patient Saf 2013;9:1-9.
11. Provonost P, Ravitz A, Stoll R, et al. Transforming Patient Safety: A Sector-Wide Systems Approach. Report of the WISH Patient Safety Forum 2015. 2015. http://cdn.wish.org.qa/app/media/1430
12. Williams PM. Techniques for root cause analysis. Proc (Bayl Univ Med Cent) 2001;14:154-7. http://www.ncbi.nlm.nih.gov/pubmed/16369607.
13. Percarpio KB, Watts BV, Weeks WB. The effectiveness of root cause analysis: What does the literature tell us Jt Comm J Qual Patient Saf 2008;34:391-8. http://www.ncbi.nlm.nih.gov/entrez/query.fcgicmd=Retrieve&db=PubMed&dopt=Citation&list-uids=18677870
14. Commission TJ. Sentinel Event Policy and Procedures. http://www.jointcommission.org/Sentinel-Event-Policy-and-Procedures/
15. Flink E, Chevalier CL, Ruperto A, et al. Lessons learned from the evolution of mandatory adverse event reporting systems. Adv Patient Saf From Res to Implement 2005;3:135-52. http://www.ncbi.nlm.nih.gov/books/NBK20547/
16. AHRQ. Root Cause Analysis. Patient Safety Primer. 2014. https://psnet.ahrq.gov/primers/primer/10/root-cause-analysis
17. Wu AW, Lipshutz AK, Pronovost PJ. Effectiveness and efficiency of root cause analysis in medicine. JAMA 2008;299:685-7.
18. Polancich S, Roussel L, Patrician P. Best practices for conducting an RCA: Are there any Patient Saf Qual Healthcare 2014. http://psqh.com/september-october-2014/best-practicesfor-conducting-an-rca
19. Peerally MF, Carr S, Waring J, et al. The problem with root cause analysis. BMJ Qual Saf 2016;doi:10.1136/bmjqs-2016-005511.
20. Perotti V, Sheridan MM. Root cause analysis of critical events in neurosurgery, New South Wales. ANZ J Surg 2015;85:626-30.
21. Mills PD, Neily J, Luan D, et al. Actions and implementation strategies to reduce suicidal events in the Veterans Health Administration. Jt Comm J Qual Patient Saf 2006;32:130-41. http://www.ncbi.nlm.nih.gov/entrez/query.fcgicmd=Retrieve&db=PubMed&dopt=Citation&list-uids=16617944
22. Faltz LL, Morley JN, Flink E, The New York model: Root cause analysis driving patient safety initiative to ensure correct surgical and invasive procedures. In: Henriksen K, Keyes MA, Grady ML, et al, eds. Advances in patient safety: New directions and alternative approaches. Rockville, MD: Agency for Healthcare Research and Quality, 2008.
23. Hettinger AZ, Fairbanks RJ, Hegde S, et al. An evidence-based toolkit for the development of effective and sustainable root cause analysis system safety solutions. J Healthc Risk Manag 2013;33:11-20.
24. Nemeth Cook RC. Reliability versus resilience: What does healthcare need Hum Factors Ergon Soc Annu Meet Proc 2007;51:621-5. http://www.ingentaconnect.com/content/hfes/hfproc/2007/00000051/00000011/art00004
25. Choksi VR, Marn C, Piotrowski MM, et al. Illustrating the root-cause-analysis process: Creation of a safety net with a semiautomated process for the notification of critical findings in diagnostic imaging.[see comment]. J Am Coll Radiol 2005;2:768-76.
26. Wears RL, Fairbanks RJ. Design trumps training. Ann Emerg Med 2016;67:316-17.
27. Gosbee J, Anderson T. Human factors engineering design demonstrations can enlighten your RCA team. Qual Saf Health Care 2003;12:119-21.
28. Varkey P, Karlapudi SP, Bennet KE. Teaching quality improvement: A collaboration project between medicine and engineering. Am J Med Qual 2008;23:296-301.
29. Xiao Y, Fairbanks RJ. Speaking systems engineering: Bilingualism in health care delivery organizations. Mayo Clin Proc 2011;86:719-20.
30. NYPORTS-The New York Patient Occurrence and Tracking System-Annual Report 1999. https://www.health.ny.gov/press/releases/2001/nyports/nyports.htm. 2001 (accessed 8 Sep 2015).
31. NYPORTS-SECTION 2: CLINICAL DEFINITIONS MANUAL. http://www.nashp.org/sites/default/files/NY-PORTS-Clinical-Definitions.pdf. Published 2005 (accessed 8 Sep 2015).
32. NCC MERP Taxonomy of Medication Errors. Rockville, MD, 2007. https://www.nccmerp.org/sites/default/files/taxonomy2001-07-31.pdf
33. Greenhalgh T, Taylor R. Papers that go beyond numbers (qualitative research). Br Med J 1997;315:740-3.
34. Pope C, Ziebland S, Mays N. Qualitative research in health care. Analysing qualitative data. Br Med J 2000;320:114-16.
35. Green M. Safety Hierarchy: Design Vs. Warnings. http://www. visualexpert.com/Resources/safetyhierarchy.html (accessed 8 Sep 2015).
36. Noble DJ, Pronovost PJ. Underreporting of patient safety incidents reduces health care's ability to quantify and accurately measure harm reduction. J Patient Saf 2010;6:247-50.
37. Rothschild JM, Landrigan CP, Cronin JW, et al. The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med 2005;33:1694-700. http://www.ncbi.nlm.nih.gov/entrez/query.fcgicmd=Retrieve&db=PubMed&dopt=Citation&list-uids=16096443
38. Rasmussen J. The role of error in organizing behavior. Ergonomics 1990;33:1185-99.
39. Joint Comission. Framework for Conducting a Root Cause Analysis and Action Plan. https://www.jointcommission.org/framework-for-conducting-a-root-cause-analysis-and-action-plan/. Published 2013 (accessed 8 Aug 2016).