When a patient safety incident or a near miss occurs and is reported, decisions are made about what to do following the event and how to determine the level of investigation, if any, the event will require. Incident investigations can entail anything from a review of the record to conducting a full Root-Cause-Analysis (RCA) process.
An RCA provides a detailed review of the facts as they appear in the record, and includes interviews with individuals involved in the event — as well as managers and peers — to capture their recollections and recommendations. Additionally, the RCA process evaluates the role that the system played in the event.
The RCA asks critical questions such as:
- Did policies, procedures, and processes exist?
- If so, were they followed?
- Were they relevant and appropriate to the event?
- Were the appropriate resources available?
In some cases, the RCA is satisfied with a detailed investigation, but other times a face-to-face meeting with a comprehensive review is needed. The comprehensive review is particularly important when an incident involves many areas of care, providers, and/or clinical or operational departments. Meetings should happen as quickly as possible so the facts are still fresh in the minds of those involved in the RCA, 72 hours is preferred.
Scheduling an RCA meeting is a major administrative commitment that consumes valuable resources, but like every other tool or therapy in health care, we want to ensure that it happens when it is necessary and likely to bring value.
The decision to convene a face to face meeting typically involves the personnel of the institutions safety leadership that many times comprise of a Patient Safety Officer, Nursing Leadership and Physician Leadership.
The advantages of the well-done RCA are numerous.
They can uncover causalities of the event that are not obvious.
Nearly every patient safety incident has multiple root causes. An RCA allows deeper understanding of the situation and helps identify the multifactorial set of circumstances that contributed to the occurrence. Think of the James Reason Swiss Cheese model and apply it to patient safety. How many layers of the cheese had to line up to allow harm to reach the patient? The RCA helps to identify and correct the different processes that contributed to the error.
Sometimes, the cause of harm seems obvious and it is tempting to shortcut the investigation. This usually happens when the cause is determined to be related to individual competence. Caution is advised in these situations. Supervisors and leaders should not automatically assume an individual is the cause of the error, because it prevents us from investigating and identifying other aspects of the system (or additional causes) that could be contributing to error. The lack of examining process may leave the system, our patients, and care providers vulnerable to making a similar mistake and prevents us from learning.
They demonstrate to staff that there is great effort put into understanding and analyzing how the work environment can contribute to mistakes.
Presuming human error as the obvious cause of incident has other negative consequences. Maintaining a healthy safety culture is especially challenging when team members feel that mistakes are held against them. This perception of punishment prevents staff from feeling that they work in a just culture, a culture that enables learning and recovery, and recognizes process failures.
Investigations can identify learning for the entire organization.
We need to create learning opportunities from patient safety incidents and near-misses. A detailed non-biased investigation will often uncover system issues that transcend a particular set of circumstances, clinical, or business unit. Lessons learned can be communicated to help increase the safety of patients throughout a given hospital, and ultimately, across the entire system. But a high level of learning is impossible without a search for the contributing factors.
Remember: If you are part of the decision-making team that is following up on a patient safety event or near-miss, consider the benefits of a well-conducted post-incident review to identify the root causes.
For an organization to develop system understanding and create a learning environment, the underlying causes need to be discovered and have the findings disseminated to prevent the same or similar events in the future.
Keeping Patients Safer 