Overview and Definitions ROOT CAUSE ANALYSIS Overview and Definitions Relationship to Patient Safety JCAHO Mission Explain what quality was nearly 20 years ago Show Sweatshirt with logo and--PFNNKA How that mentality has stayed with us. 1

THE GOAL Eliminate preventable medical errors Fulfill the mission to provide safe medical care Develop realistic action plans which force system change Move “beyond blame” 4

CREATING AN ATTITUDE OF SAFETY Systems failures are the root cause of most preventable errors Systems produce the outcomes they are designed to produce System and Process change is possible 3

PATIENT SAFETY Focuses on broken processes/systems not individuals Recognizes value of process owner input Promotes multidisciplinary approach to problem solving Foster communication skills Identifies critical success factors 3

PATIENT SAFETY Seeks objective analysis Uses evidence based approach for change recommendations Monitors for effectiveness Provides feedback Integrates change throughout the organization 3

JCAHO Defines Sentinel Events for accredited organizations Requires thorough and credible review Requires evidence based action plan Emphasizes leadership’s role in the solutions Requires 6 month follow up to document effectiveness of actions taken 3

DEFINITIONS Adverse events Sentinel events Close calls Intentional unsafe acts Root cause analysis Contributing factors Root cause Action plan 8

ADVERSE EVENTS Broad group of errors directly associated with care Includes Sentinel Events Therapeutic misadventures Iatrogenic injuries Falls, medication errors 9

SENTINEL EVENT Type of adverse event Unexpected occurrences involving death, serious injury, or risk thereof Serious injury includes loss of limb or function 10

SENTINEL EVENT “Risk thereof” = a recurrence carries a significant chance of serious adverse outcome “Major permanent loss of function “ Sensory, motor, physiologic or intellectual impairment not previously present Requires continued treatment or life-style changes 11

JCAHO SENTINEL EVENTS Death from medication or treatment error Patient suicide in a round-the-clock setting Surgery on the wrong patient or body part Hemolytic transfusion reaction All are Catastrophic Events (see SAC matrix) 12

CLOSE CALLS Errors that did not reach the patient Could have resulted in an accident, injury or illness, but did not Also known as “near miss” 13

CLOSE CALL RESPONSIBILITY Recognize opportunity to fix the system before it breaks Recognize symptoms of broken processes and systems Prioritize the level/extent of the investigation Recommend investigation using the RCA methodology 16

INTENTIONAL UNSAFE ACTS Adverse event that results from: Criminal act Purposefully unsafe act Related to alcohol or substance abuse/impaired provider/staff Alleged patient abuse Not part of the patient safety program 17

ROOT CAUSE ANALYSIS Identifies weakness in processes and systems Identifies basic or contributing causes to the error Focuses results on preventing and minimizing future risks Requires multidisciplinary involvement in the process and solutions 3

WHAT IT DOES: Questions: What happened? Why it happen? What can you do to prevent it from happening again? What can you do to minimize future risks? Recommended several steps to unify the Nation in improving the quality of healthcare Report noted that many organizations, including several Federal agencies were involved in important efforts to improve quality, but the lack of coordination made it difficult for healthcare providers and was confusing to the public 2

HOW IT WORKS: Systematic method for problem solving Uses a series of objective questions (triage) Digs deeper by asking why, why, why??? Focuses on six major causes of errors 3

FACTORS Communication Staffing/Fatigue Training Environment/Equipment Barriers (alarms) Rules: policies/procedures 4

ROOT CAUSE VS. CONTRIBUTING FACTORS Fundamental reason a problem has occurred Eliminate the cause and prevent a similar adverse event Contributing: Additional factors which compounded the error 18

ACTION PLAN Develops & implements improvement strategies Addresses system/process deficiencies Includes measures, time frame and responsible party 21

ACTIONS TYPES Eliminate -remove concentrated KCL Control- lowest dose of medication reduces risk Accept- alerts/warnings-caution be on guard 22

ACTION FOLLOW-UP Assigns responsibility for each action item Provides a “tickler” system for tracking Assesses effectiveness of each action item 23

ADDITIONAL TOOLS Brainstorming Flowcharting Cause and Effect diagrams Barrier analysis Triage questions Time line of events 24

TRIAGE QUESTIONS Memory jogger Helps the team ask “why”? Provides a structured assessment Second check on completeness of flow charts/diagrams 26

RETURN ON INVESTMENT Provides a focused, systematic approach to problem solving Involves process owners Improves communication among staff Increases opportunity for buy in and success Reduces rework 26

RETURN ON INVESTMENT Requires Leadership accountability Promotes prioritization of resources Supports the mission “provision of safe medical care” 26

REFERENCES JCAHO (www.JCAHO.org) Sentinel Events Scholtes, P.R. (1991). The team handbook. WI: Joiner Associates, Inc. 25