Although performing a root cause analysis (RCA) after an adverse event has become standard practice in many health care organizations, there is little evidence to support that this process has improved patient safety.1 Organizational culture plays a large part in the success of an RCA; there are fundamental issues in the structure of the RCA process to address as well. The following is a list of a few issues identified in the literature that create barriers to a successful RCA:
lack of time and training,
unwilling colleagues and lack of spread, and
weak corrective action plans without follow-up.2
Lack of time and training
Most people performing RCAs have not received formal or adequate training. The RCA process may not be developed or clear to everyone involved, which may result in an inadequate investigation, identification of causal factors and development of a meaningful corrective action plan. A recent study by Bowie et al indicates that respondents with formal RCA training were more likely to conduct follow-up sessions after conducting an RCA as well as receive peer feedback on the effectiveness of the process.3
In addition to lack of training, many organizations only perform RCAs when a harmful event has occurred. This may be due to a lack of time and resources committed to performing RCAs, as well as an inadequate process. As we advance in patient safety, RCAs should be used more proactively on near misses and no-harm events.
Unwilling colleagues and lack of spread
Key people within the organization need to be involved in order to make the process effective; physician and leadership participation is vital to sustainable success. It is impossible to make true system-wide changes unless all disciplines in the organization take ownership of the safety issues involved.
Often, teams that performed an RCA after an event occurred in a specific department do not feel empowered to make improvements beyond their own setting and therefore only focus on ways to address the immediate problem within that specific department. The result can be devastating when system-level failures are not addressed and preventable errors continue to occur.
Furthermore, few organizations feel confident enough in their analysis to contact someone outside of their organization, like a medical device manufacturer, about the identified need to redesign their product. Working with organizations that have statewide and national reach, like CHPSO,can help raise awareness at the manufacturer level.
Weak corrective action plans without follow-up
Corrective action plans typically focus on training and policy development, rather than redesign of processes and products that will have more success in addressing human error. The design and implementation of solutions is as important as the solution itself. Implementing an IT solution may be seen as a “cure-all”, but it will only be effective if appropriate analysis and input were included in the development of the solution. Were the front-line users involved in designing the solution? If not, and realistic workflow and environmental concerns were not considered, the solution may actually create another hazard. For example, a solution identified in a corrective action plan now causes a nurse to leave his area and go to another department to sign-out a piece of equipment. Additional safety hazards may occur if there is no one monitoring his patients when he is away from the department. Workarounds are created when solutions are complicated and difficult to implement. As a workaround, this nurse may decide to take this piece of equipment he recently used on another patient from the dirty utility room and do a quick wipe-down rather than go to another department to sign-out a piece of equipment. The key to making any effective change is that it must support rather than hinder or create a barrier for the end-user.
Once the corrective action plan is created, it should be monitored to ensure that 1) it is fully adopted into practice and 2) the problem is resolved. If neither of these objectives were accomplished, the RCA team should reconvene, ask “why”, and address those issues until a successful plan is implemented.
When this process was adopted from the manufacturing industry, it was done so with the intention of improving safety, and there is still the potential for this to be successful if performed correctly. CHPSO offers members complimentary critique of the RCA process with additional consultation as requested. If you would like to learn more about these activities, please contact CHPSO at firstname.lastname@example.org.
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. Journal Healthcare Risk Management. 2013;33(2):11-20.
Braithwaite J, Westbrook MT, Mallock NA, et. al. Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme. Qual Saf Health Care. 2006 Dec; 15(6):393-9.
Bowie P, Skinner J, and de Wet C. Training health care professionals in root cause analysis: a cross-sectional study of post-training experiences, benefits and attitudes. BMC Health Serv Res: 2013; 13:50.