1. CREOG Patient Safety Series: Safety in Women’s Healthcare
High Reliability Organizations (HRO)
Root Cause Analysis (RCA)
Module 10

2. Clinical Correlation
While on L&D, the residents participate in drills for the management of obstetric emergencies with teams of OB attendings, L&D and nursery nurses, anesthesia personnel and simulated patients. This activity is characteristic of a Highly Reliable Organization (HRO) because
A. It teaches the residents their place in the organization’s hierarchy.
B. It detects individuals whose training has been inadequate.
C. It teaches residents to rely on technologic safety mechanisms
D. It teaches residents that anyone can “Stop the Line” when he/she recognizes an unsafe situation

3. Clinical Correlation
While on L&D, the residents participate in drills for the management of obstetric emergencies with teams of OB attendings, L&D and nursery nurses, anesthesia personnel and simulated patients. This activity is characteristic of a Highly Reliable Organization (HRO) because
A. It teaches the residents their place in the organization’s hierarchy.
B. It detects individuals whose training has been inadequate.
C. It teaches residents to rely on technologic safety mechanisms
D. It teaches residents that anyone can “Stop the Line” when he/she recognizes an unsafe situation

4. Safety in the HRO Safety is not left to chance
There is hierarchy, but safety takes precedence
Everyone’s training allows for low-level decision making
When you identify a problem (no matter your rank), you own it until it is solved or someone who can solve it takes over
Alarms can be called by anyone to “Stop the Line”
a word or phrase understood by all in recognition of an unsafe situation and can be used with an awake patient

5. Teamwork in the HRO Teamwork is the key operating principle
Tight coupling and task interdependence
Team interaction is collegial not hierarchical
Team responds more efficiency than individuals
Effective teamwork is subject to ongoing examination and improvement
Teams design systems to prevent, detect, and minimize errors rather than blame individuals.

6. Communication in the HRO
Communication is open and extensive
Respects the value of different perspectives
Uses debriefings routinely
Minimizes hierarchy

7. Clinical Correlation
Which of the following are considered characteristics of high reliability organizations?
A. Safety is left to chance
B. There is no hierarchy
C. Alarms can only be called by physicians
D. There is a commitment to resilience
E. (a), (b) and (c)

8. Clinical Correlation
Which of the following are considered characteristics of high reliability organizations?
A. Safety is left to chance
B. There is no hierarchy
C. Alarms can only be called by physicians
D. There is a commitment to resilience
E. (a), (b) and (c)

9. Root Cause Analysis (RCA)
Retrospective approach to error analysis
Foundations in industry psychology and human factors engineering
The Joint Commission mandates the use of RCA in investigation of sentinel events
RCA provides a structured and process-focused framework for analysis
Cardinal tenet is to avoid individual blame

10. Examples of Joint Commission’s Reviewable Sentinel Events
Patient death associated with a medication error
Intrapartum maternal death
Perinatal death unrelated to a congenital condition in an infant weighing more than 2500g
Infant abduction
Patient fall resulting in death or permanent loss of function
Hemolytic transfusion reaction involving major blood group incompatibilities
Retained foreign body after surgery

11. Steps in Performing an RCA
Form a Root Cause Analysis Team
Identify Problem
Gather information /evidence
Determine the Root Causes and
Contributing Factors
Explore risk reduction and Quality improvement strategies
Implement Redesigns
Monitor and evaluate new system

12. Clinical Correlation
The Joint Commission mandates that a review of events be performed
A. When an infant weighing more than 2500g dies on the first day of life from an undetected congenital heart anomaly.
B. When a vaginal pack is intentionally left in place after an anterior repair.
C. Retrospectively after a sentinel event has occurred.
D. To identify the individual at fault for a medical error that resulted in a sentinel event.
E. To definitively establish the root cause of an adverse event.

13. Clinical Correlation
The Joint Commission mandates that a review of events be performed
A. When an infant weighing more than 2500g dies on the first day of life from an undetected congenital heart anomaly.
B. When a vaginal pack is intentionally left in place after an anterior repair.
C. Retrospectively after a sentinel event has occurred.
D. To identify the individual at fault for a medical error that resulted in a sentinel event.
E. To definitively establish the root cause of an adverse event.

14. RCA Limitations RCA is in essence uncontrolled case studies
Impossible to know if root cause established by analysis is cause of the accident
Hindsight bias
Other biases stem from how deeply causes are probed and prevailing concerns of the day
Time consuming and labor intensive

15. Failure Mode and Effect Analysis (FMEA)
A prospective assessment that identifies and improves steps in a process and ensures a safe and desirable outcome
Process map – team lists all the failures that could occur at each task
Specify the potential causes, effects and severity of each failure
Assess the likelihood of each occurrence and the probability of detecting the cause before harm is done
The severity, probability, and detectability are ranked on a 10-point scale and multiplied to determine a risk priority number (RPN)
The risk priority after the prevention effort should be less severe, less likely to occur, or more easily detected

16. Clinical Correlation
In a Failure Mode and Effects Analysis (FMEA), a team of health professionals prospectively analyses a process to predict where failures might occur. This activity
A. is often a regulatory requirement.
B. evaluates near misses and sentinel events.
C. encourages residents to acknowledge responsibility for potential errors.
D. is intended to reduce the likelihood of an undesirable outcome.

17. Clinical Correlation
In a Failure Mode and Effects Analysis (FMEA), a team of health professionals prospectively analyses a process to predict where failures might occur. This activity
A. is often a regulatory requirement.
B. evaluates near misses and sentinel events.
C. encourages residents to acknowledge responsibility for potential errors.
D. is intended to reduce the likelihood of an undesirable outcome.

18. Summary RCA is a retrospective response to errors
RCA evaluates sentinel events and near misses
RCA may be a regulatory agency requirement
FMEA is a prospective process to prevent errors
Both concentrate on system issues and avoid
individual blame
RCA and FMEA are part of a continuous quality
improvement program

19. CREOG Patient Safety Series: Safety in Women’s Healthcare
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Congratulations!
You have completed
High Reliability Organizations and RCA
Module 10