1. Using Root Cause Analysis to Make the Patient Care System Safe John Robert Dew The University of Alabama

2. JCAHO Alerts in 2001: Patients catching on fire. Deaths due to mix-up of gases. Disease transmission through surgical instruments. Transmission of blood bourne pathogens through needle sticks. Wrong side/wrong procedure/wrong person surgeries.

3. All locations vulnerable: Hospital-based ambulatory care units. Freestanding ambulatory care units. Inpatient operating rooms. Inpatient emergency rooms. In-home care.

4. Complex Systems Testing & Analysis Diagnosis Treatment Patient tracking Facility maintenance Equipment operation Controlled Substances

5. Adverse and Sentinel Events “Unintended injury to patients resulting from a medical intervention, which includes any action by healthcare workers, including clerical and maintenance staff.” Institute of Medicine “An unexpected occurrence involving death or serious physical or psychological injury or risk thereof.” Joint Commission

6. Immediate Causes: Deviations between what should occur and what actually occurred. The immediate cause may be disguised by complexity of events. Important to be able to ask diagnostic questions: what, where, when, extent, is and is not.

7. What is a root cause? A root cause is the most basic causal factor, or factors, which if corrected or removed will prevent the recurrence of a situation, such as an error in performing a procedure. Root causes create the setting for immediate causes of problems.

8. Why do root causes exist? Adverse and sentinel events are symptoms of a pathology in the organization. What is the disease that is eating away at the organization? A disease in an organization can cause collapse of multiple work systems.

9. Root Cause Analysis:... Is a questioning process. There are several tools that will provide structure to this questioning process to assist organizations in the examination process.

10. Several Methods of Root Cause Analysis: Questioning to the Void Event & Causal Factor Analysis Safeguard Analysis

11. Questioning to the Void A systematic approach of asking questions: How is it that? What do we know about...? In Japan, called the Five Whys.

12. Event & Causal Factor Analysis Work order written for Oxygen Maintenance Shuts off oxygen Staff reports Patients are Gasping. Valves not Labeled Staff thinks oxygen cut off Wrong Valve Closed Staff not briefed

13. Safeguard Analysis SOURCEVICTIM SAFEGUARDS

14. Steps in Safeguard Analysis Identify potential or actual source of an event and identify the actual or potential victim. Identify safeguards currently in place and determine effectiveness. Develop plan to strengthen weak safeguards. Identify/deploy new safeguards.

15. Hierarchy of Safeguards Physical Natural Information Measurement Knowledge Administrative

16. Problems with root cause taxonomies: Most root causes are identified as being related to a weakness in the management system. Consistent with Dr. Deming’s observations. Most root cause categories do not dig deep enough.

17. Dew’s Taxonomy of Root Causes Placing budget considerations ahead of patient safety and quality. Placing schedule considerations ahead of patient safety and quality. Placing political considerations ahead of patient safety and quality. Arrogance. Lack of understanding, knowledge. Sense of entitlement among the staff.

18. Pathological behaviors: Rationalization Illusion of invulnerability. Self-censorship. Direct pressure on deviants. Breed within the organization. People who continue to disagree are forced out.

19. References Diagnosing and Preventing Adverse and Sentinel Events. John Dew and Meri Curtis. Opus Communications, 2001. Sentinel Events: Evaluating Cause and Planning Improvement. Joint Commission on Accreditation of Health Care Organizations. 1998.