Root Cause Analysis

  • Serious Adverse Events
  • Structured method to analyze events
  • Identifies underlying problems
  • Follows a prescribed protocol
  • Includes data collection and reconstruction of event
  • Uses a variety of strategies
  • Ultimate goal is preventing future harm by eliminating latent errors

Adapted from ARHQ PSNet

Li Ka Shing Knowledge Institute - St. Michael's Hospital by JasonParis is licensed under CC BY 2.0.

Root Cause Analysis Tools

5 Why Analysis

  • Repeatedly ask “why” to uncover problem beyond symptoms.
  • Ask “why” until the root cause is revealed.

Fishbone/Ishikawa

  • Graphically represents potential causes of a problem.
  • Allows comparison of multiple elements.

5 Why Analysis Example

THE SAFETY CASE

A laboratory aide was cleaning one of the gross dissection rooms where the residents work. This aide was a relatively new employee who had transferred to the department just a few days prior to the event. When she was cleaning the sink in the dissection room, she accidentally ran her thumb along the length of a dissecting knife - an injury that required 10 to 15 stitches. Since there had been other less serious accidents in this room and several previous attempts to address the safety issues had not been effective, the department completed a root cause analysis.

Adapted from US National Library of Medicine National Institutes of Health

  • Problem
  • Why?
  • Why?
  • Why?
  • Why?
  • Standard operating procedures/ documentation for clearing do not exist.
  • The area was not cleared on the previous day.
  • Clearing is not a daily habit.
  • The knife was left by the sink.
  • A laboratory aide was cut by a dissection knife.
  • Problem
  • Why?
  • Why?
  • Why?
  • Why?
  • A laboratory aide was cut by a dissection knife.
  • The knife was left by the sink.
  • The area was not cleared on the previous day.
  • Clearing is not a daily habit.
  • Standard operating procedures/ documentation for clearing do not exist.

Fishbone/Ishikawa Diagram

A 56-year-old female with dysfunctional uterine bleeding and possible retained intrauterine device (IUD) was scheduled for elective hysteroscopy and dilation and curettage (D&C). Of note, she had recently completed a course of tetracycline for an asymptomatic infection with Actinomyces israelii discovered on Pap smear. After the patient was in the operating room and prepared for the procedure, the team discovered that the equipment typically used for hysteroscopy was unavailable - the case had been listed only as a "D&C" on the operating room (OR) schedule, so the hysteroscopy set had not yet been sterilized after use earlier in the day. To avoid cancelling the procedure, the team borrowed sterile parts from various other hysteroscopy sets.

During insufflation of the uterus, the patient suffered cardiac arrest presumably related to air embolus. The patient was successfully resuscitated. After an 8-day stay in the intensive care unit, the patient was discharged home with no permanent sequelae.

Adapted from US D H&HS Agency for Healthcare Research and Quality

Patient factors Clinical condition
Physical factors
Social factors
Psychological/
mental factors
Interpersonal
Relationships
Individual
staff factors
Physical issues
Psychological
Social/domestic
Personality
Cognitive factors
Task factors: Guidelines/
procedures/
protocols
Decision aids
Task design
Communication factors:
Verbal
Written
Non-verbal
Management
Team factors:
Role congruence
Leadership
Support + cultural factors
Education + Training
Factors:
Competence
Supervision
Availability/
Accessibility
Appropriateness
Equipment +
resources

Displays
Integrity
Positioning
Usability
Working condition factors: Administrative
Design of physical
environment
Staffing
Workload and hours
Time
Organisational +
strategic factors:
Organisational structure
Priorities
Externally imported risks
Safety culture
problem also dumped here

Adapted from NHS National Patient Safety Agency

Pt w/uterine bleeding & possible retained IUD
Pt scheduled for elective hysteroscopy and D&C
Pt recently completed ABs for infection found on Pap
Hysteroscopy equipment was missing from OR
The case was listed as a D&C only on OR schedule
Hysteroscopy set had not yet been sterilized from earlier use
Team wanted to avoid having to reschedule the procedure
Team borrowed sterile parts from other hysteroscopy sets
During insufflation of uterus, pt suffered cardiac arrest
Staff presumed cardiac arrest was due to air embolus
Pt was successfully resuscitated
Pt required 8-day ICU stay
Pt was discharged home with no permanent sequelae
Patient factors Clinical condition
Physical factors
Social factors
Psychological/
mental factors
Interpersonal
Relationships
Individual
staff factors
Physical issues
Psychological
Social/domestic
Personality
Cognitive factors
Task factors: Guidelines/
procedures/
protocols
Decision aids
Task design
Communication factors:
Verbal
Written
Non-verbal
Management
Team factors:
Role congruence
Leadership
Support + cultural factors
Education + Training
Factors:
Competence
Supervision
Availability/
Accessibility
Appropriateness
Equipment +
resources

Displays
Integrity
Positioning
Usability
Working condition factors: Administrative
Design of physical
environment
Staffing
Workload and hours
Time
Organisational +
strategic factors:
Organisational structure
Priorities
Externally imported risks
Safety culture

Adapted from NHS National Patient Safety Agency

Well Done! Using a Fishbone Diagram can be useful when analyzing the details of complex events. It allows for comparison of a variety of factors that may have contributed to the event. Now you will use this to determine the root cause.

Adapted from NHS National Patient Safety Agency

Patient factors Clinical condition
Physical factors
Social factors
Psychological/
mental factors
Interpersonal
Relationships
Pt recently completed ABs for infection found on Pap
Pt w/uterine bleeding & possible retained IUD
Pt was discharged home with no permanent sequelae
Pt required 8-day ICU stay
Individual
staff factors
Physical issues
Psychological
Social/domestic
Personality
Cognitive factors
Staff presumed cardiac arrest was due to air embolus
Task factors: Guidelines/
procedures/
protocols
Decision aids
Task design
Pt scheduled for elective hysteroscopy and D&C
Communication factors:
Verbal
Written
Non-verbal
Management
Team factors:
Role congruence
Leadership
Support + cultural factors
Team wanted to avoid having to reschedule the procedure
Pt was successfully resuscitated
Education + Training
Factors:
Competence
Supervision
Availability/
Accessibility
Appropriateness
Hysteroscopy equipment was missing from OR
Hysteroscopy set had not yet been sterilized from earlier use
Equipment +
resources

Displays
Integrity
Positioning
Usability
The case was listed as a D&C only on OR schedule
Working condition factors: Administrative
Design of physical
environment
Staffing
Workload and hours
Time
Team borrowed sterile parts from other hysteroscopy sets
Organisational +
strategic factors:
Organisational structure
Priorities
Externally imported risks
Safety culture
During insufflation of uterus, pt suffered cardiac arrest
Patient Factors: Correct! In this real-life case, the Root Cause Analysis determined that the patient’s pre-existing condition was the Root Cause of the cardiac arrest.
Individual (staff) Factors: While the staff made an incorrect assumption, this was not the root cause of the event.
Task Factors: The patient was scheduled for the correct procedure, this was not the cause of the adverse event.
Communication Factors: There were no communication factors that contributed to this event.
Team factors: The team’s desire to avoid the procedure being rescheduled was not a root cause of the problem, though it is a cause for concern.
Organizational/Strategic Factors: The team borrowing sterile parts from other hysteroscopy sets is a practice that should be addressed, but was not the root cause of the cardiac arrest.
Working Condition Factors: Though the lax OR schedule procedure should be addressed, it was not the root cause of the cardiac arrest.
Equipment and Resources: There were several equipment issues that may have contributed to the adverse event, and these should be addressed, but they were not the root cause of the cardiac arrest.
Education + Training Factors: The staff’s education and training was successful in allowing them to resuscitate the patient, therefore it is not the root cause of the adverse event.

Adapted from NHS National Patient Safety Agency

Congratulations! You have successfully identified the root cause in two unique cases involving adverse events.

In the following activity, you will use this experience to imagine a scenario where you are responsible for overseeing an investigation regarding an adverse event.

2018_0316_OSUCascades_Hospitality_JennaBrasada-38(2) by Oregon State University is licensed under CC BY-SA 2.0.

There was a recent event whereby a patient received a drug resulting in a negative outcome.
You must: complete a Root Cause Analysis on the event in preparation for the visit from the county health official.

To Do:


  • Complete a Root Cause Analysis on the adverse event.
  • Outline in 3 pages all the steps that will be taken to determine the cause of the event.
  • Write a brief 1-page memo explaining steps that will be taken to mitigate these issues in the future.
  • Use the reading and information from the course and the activities to aid your reports.
  • This information will be used for a future assignment, so it will be helpful to be thorough.