Root Cause Analysis (RCA) for the Improvement of Healthcare Systems and Patient Safety

David Allison, CPPS, Harold Peters, P.Eng.

• Publisher: CRC Press
• Year: 2021
• ISBN:
  9781000430066
• Edition: 1
• Topic: Negocios y empresa
• Subtopic: Sector de servicios

The book follows a proven training outline, including real-life examples and exercises, to teach healthcare professionals and students how to lead effective and successful Root Cause Analysis (RCA) to eliminate patient harm.

This book discusses the need for RCA in the healthcare sector, providing practical advice for its facilitation. It addresses when to use RCA, how to create effective RCA action plans, and how to prevent common RCA failures. An RCA training curriculum is also included.

This book is intended for those leading RCAs of patient harm events, leaders, students, and patient safety advocates who are interested in gaining more knowledge about RCA in healthcare.

Part I

Building an Understanding of RCA

1The Need for Root Cause Analysis (RCA)

1.1 Why Investigate Healthcare Unintended Events?

Let us begin with a reflection on why we should devote the time and resources to thorough and rigorous root cause analysis (RCA). Empathy is an oft-strived-for attribute in healthcare and frequently associated with compassion. In fact, the Latin root of compassion means to suffer alongside. Being empathic as caregivers helps us appreciate the patients’ perspective: we are better attuned to their fears and concerns, hopes, and desires. Such compassion yields greater alignment of goals for recovery. When unintended events occur, resulting in patients being harmed, our empathy motivates a caring response. However, compassion as empathy alone will not be sufficient to prevent the unintended event from reoccurring, resulting in the harm of a future patient.

Compassion, comprised of both empathy and intellectual understanding, is called for in caring for patients who have been harmed and for those who have made errors that result in harm. In addition to our affective response, compassion in healthcare requires using our intellect. We need to employ the scientific method to discover causes and learn how to prevent harm. Don Berwick¹ drew lessons for the future of healthcare from Norman MacLean’s book, Young Men and Fire.² In the moving story of the 1949 Mann Gulch fire near Helena, Montana, in which 13 young men lost their lives, MacLean carefully reconstructs the fateful sequence of events. MacLean explains how the factors of weather, terrain, and characteristics of fire all combined to result in a small fire blowing up into a conflagration, and he helps understand the decisions made by members of the crew that resulted in their lack of escape. He also tells the remarkable story of crew chief Wag Dodge, who spontaneously invented the escape fire and survived. The power of root cause analysis is in the depth of understanding gained in breaking down how a tragic event occurred, to prevent it from reoccurring. That is why we perform RCA on healthcare unintended events.

1.2 Caring for Caregivers

We are in a period of transition from a history of “shame and blame” to one of “caring for the caregivers.” Physicians, nurses, technologists, pharmacists, and therapists are among the disciplines in healthcare most vulnerable to making human errors. As an industry, we have been constrained under a system of litigation that drives practitioners to be advised not to speak about an error with anyone but their legal representatives. This milieu of shame and silence can compound tragedy upon tragedy.

European researchers³ found healthcare professionals identified three needs after an error caused patient harm. There is a need for peer support. There is a desire for support from management. And there is a need for stable and transparent analysis. Models of peer support are emerging across healthcare. Sue Scott⁴ of the University of Missouri has written extensively on the impact of a peer support program. Others such as the Medically Induced Trauma Support Services (MITSS)⁵ and the Johns Hopkin Resilience in Stressful Events (RISE)⁶ programs serve as models for emotionally supporting caregivers. Matthew Syed⁷ suggests the need for resilience: “The capacity to face up to failure, and to learn from it. Ultimately, that is what growth is all about.”

Thorough and rigorous RCA is one way in which a healthcare organization supports a shift from blaming caregivers to becoming a learning organization. A premise for our RCA practice has been the assumption that those involved in unintended events are skilled and dedicated caregivers: it has been rare to find reckless behavior. However, we also understand that the same error will likely reoccur unless there are changes made to prevent it.

We advocate for including caregivers involved in an unintended event on the RCA team. Others have suggested a different approach out of concern “that they may feel guilty and insist on corrective measures that are above and beyond what is prudent, or they may steer the team away from their role in the event and activities that contributed to the event.”⁸ Our approach to RCA team composition will be spelled out in Chapter 3. For now, we note one of the important reasons for doing RCA is the opportunity it affords caregivers to be involved in improving safety for future patients and their colleagues. Gaining the understanding of how the system failed and how the caregiver is not a terrible person is a consistently positive experience for those directly involved in a healthcare error.

RCA that rigorously drives to the latent system vulnerabilities, as commonly depicted by James Reason’s “Swiss cheese” model,⁹ aligns with an understanding of accountability based on just culture. Caregivers are more likely to speak up and identify safety concerns in an atmosphere where they feel psychologically safe. Root cause analysis helps to understand the mutual accountabilities of the individual caregiver and the healthcare organization through understanding the process and system-related failures that result in healthcare-unintended events.

1.3 Systems Approach

The National Patient Safety Foundation looked back 15 years after the publication in 1999 of the seminal work, To Err Is Human.¹⁰ The findings were published in the white paper, “Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human.”¹¹ The panel observed that two general approaches had evolved to improving patient safety over the prior 15 years. One strategy was to identify specific safety problems and approach them on a project-by-project basis. The panel found that this strategy had not led to widespread improvements despite remarkable singular successes. A second strategy sought to emulate other industries that took more of a systems approach. This approach led to the following conclusion, “By taking into account systems design, human failures, human factors engineering, safety culture, and error reporting and analysis, the systems approach epitomizes a more comprehensive view.”¹² To understand how RCA contributes to a systems approach, and its value for improving patient safety, it is helpful to reflect on the experience of commercial aviation safety.

1.3.1 Aviation’s Breakthrough

The commercial airline industry in the United States, as early as the 1970s, had achieved significant progress in preventing crashes and fatalities. Jet aircraft, with increased capabilities to avoid hazards, had become the industry norm. Human factors engineering had aided cockpit design. Checklists had been utilized since World War II. But even with these improvements, crashes and fatalities continued. More recently, during the years 2010–2017, U.S. commercial carriers achieved a record of zero fatalities (see Table 1.1 for the data).¹³ How did they accomplish this? The story begins with the crash of United Airlines Flight 173 on December 28, 1978.¹⁴

Table 1.1
U.S. Commercial Carrier Passenger Fatalities

Passenger Injuries and Injury Rates, 1999 through 2018, for U.S. Air Carriers Operating under 14 CFR 121
Year	Passenger Injuries		Passenger Enplanements (millions)	Million Passenger Enplanements per Passenger Fatality
	Fatalities	Serious Injuries
1999	10	46	676	67.6
2000	83	13	701	8.4
2001	483	7	629	2.5
2002	0	11	619	No Fatalities
2003	19	10	654	34.4
2004	11	3	711	64.6
2005	18	2	743	41.3
2006	47	4	747	15.9
2007	0	3	770	No Fatalities
2008	0	6	745	No Fatalities
2009	45	14	706	15.7
2010	0	5	723	No Fatalities
2011	0	4	734	No Fatalities
2012	0	3	740	No Fatalities
2013	0	1	746	No Fatalities
2014	0	0	766	No Fatalities
2015	0	8	801	No Fatalities
2016	0	4	826	No Fatalities
2017	0	1	851	No Fatalities
2018	1	10	891	890.9

Flight 173 crashed after running out of fuel while the pilot and cockpit crew were trying to determine if the landing gear was locked down upon approach to the Portland International Airport. They did not hear the expected click of the gear locking into place. Instead, they heard a thud. A light didn’t illuminate to indicate the landing gear was locked down. What was happening?

The pilot was an experienced veteran with more than 27,000 flight hours. The firs...