Concern with Root Cause Analysis and its use in Medicine to mitigate risk.
Root cause analysis (RCA) identifies the fundamental and contributory factors that emphasize variation in performance. It is a systematic retrospective review of occurrences / mishaps / errors that has been widely used in several industries as means of correcting problems. Originally developed in psychology, it has been successfully implemented in aviation and nuclear power; it has become quite popular with error management in healthcare organizations. How good is it in resolving problems?
A simple triad of questions forms the basis of investigation: what happened, why did it happen, and what can be done to keep it from happening again? A fourth question typically needs to be asked with regard to medical issues: has the threat of reoccurrence actually been mitigated? From the Journal of American Medical Association (JAMA) Dr. Wu et al repot that there is concern whether the amount of resources expended of RCA are in fact being wasted.
Research has demonstrated that a wide variation in the use and implementation of RCA exists from one healthcare system to another. In similar fashion the States also vary. Dr. Wu et al provided data regarding the use of RCA with the U.S. Department of Veterans Affairs (VA) which showed a focus shift of causes from the individual to organizational – systemic – and policy flaws. Additional data showed that there was little follow up in terms of corrective action to see if indeed the corrective recommendations had been implemented, and to see if they had been effective.
Dr. Wu et al suggest that several problems exist with the improper use of RCA and the lack of useable results from the investigative process. Health department officials have noted that the quality of RCA completed also varies quite a bit. Wu et al further states that in medicine hospitals typically have recurrent errors even after the completion of an RCA which the team quite appropriately cite Einstein – “Insanity is doing the same thing and expecting a different result.”
The conclusions obtained included corrective action recommendations to come from a higher level – the healthcare system as apposed to the individual hospital, achieving a consensus amongst stakeholders regarding the level and of type of action to take, implementing pilot recommendations and reviewing the effects, and then make revisions prior to full implementation.
The commentary from Dr. Wu et al suggests the development of a national oversight assembly that would ensure best practices for conducting RCA investigations and implementing corrective actions.
The RCA process is clearly effective. Dr. Wu et al brings to light the lack of expertise that I dare say many healthcare organizations have with performing quality investigations. It appears that healthcare systems or single entity facilities are completing investigations in isolation without the benefit of a national database or similar resource to help achieve high-quality outcomes from the RCA process – a reinventing the wheel if you will.
In today’s competitive healthcare market coupled with tidal shifts in insurance reimbursements, it is imperative that healthcare organizations place preventable error management in the forefront of strategic planning. A balance of high quality care, careful resource management, and fiscal prudence will be the attributes of organizational success in meeting the healthcare needs of the future.
Wu, A. (2008). The effectiveness and efficiency of root cause analysis in medicine. JAMA, 299(6), 685-687.
About the Author
Mike Pringle is the creator of Mike’s ViewPoint, where he provides his perspective on various Healthcare issues. He has over 20 years of nursing experience working both domestically and internationally. Mike has a Bachelor’s Degree in Nursing and a Masters Degree in Public Administration with a healthcare emphasis. He specializes in both Emergency and Critical Care Nursing. Mike has held positions ranging from department staff and Nurse Manager to Executive positions.
