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

2. 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

3. 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

4. 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

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

6. 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

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

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

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

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

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

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

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

14. 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

15. 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

16. 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

17. 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

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

19. 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

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

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

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

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

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

25. 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

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

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