Overview of Root Cause Analysis Brian Harmon Quality Consultant Performance Improvement University of Minnesota Medical Center February 25, 2006 What is a Sentinel Event? A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called "sentinel" because they signal the need for immediate investigation and response. 1
Advent of a Root Cause Analysis An adverse or potentially adverse event occurs Reported by front-line staff to management Reported to Risk Management Risk informs Administration & Quality Assurance A determination meeting is called Determination Meeting Attended by Risk Management, Senior Administration, Quality Assurance, Managers or Medical Directors of affected departments Determine severity of event (via extent of patient harm) and type of analysis to be performed Identify stop-gap fixes already performed Suspension of billing Disclosure Determine team to perform root cause analysis 2
Basic Elements of a Root Cause Analysis Chronology of Events ( What( Happened? ) Define the Problem ( What( Went Wrong? ) Brainstorm Potential Causes of the Problem Review Brainstorm List: Prioritize and Rule Out Determine the Root Cause Develop Action Plan to Address the Root Cause Chronology of Events Get event details from all relevant players/perspectives as comprehensively as possible Identify the error points (there may be many) How far from the bedside was the initial error? Did the error reach the bedside? How close did it get? Identify systems and processes that may have failed. Which are formal? Informal? Try to exhaust what before worrying about why 3
Define the Problem Boil the chronology down to a single statement of what went wrong The problem statement determines the focus of the why questions Types of Problems Medication Errors Overdose/Oversedation Oversedation Wrong Drug/Wrong Patient Surgical or Procedural Complications Retained Objects Wrong Site/Wrong Side/Wrong Patient Improper Use of Equipment Unexpected Death or Disability Product or Device Failures Contamination Malfunction 4
Types of Problems Patient Behavior Suicide Attempts/Self-Injurious Behavior Elopement Assault/Rape/Homicide Abduction Delays in Treatment Environmental Failures Falls Burns/Shocks Restraints Physical Plant Malfunctions Types of Problems Care Management Adverse/Allergic Reactions Pressure Ulcers Specimen Handling Incompatible Blood Products Transfusion Complications Unexpected Death or Disability 5
Identifying Causes of Problems Think about the error points: how many and how often The distance of the initial error from the patient s s bedside is a useful (though rough) indicator of the extent and number of systems or processes that are in need of attention Distance of Initial Error from Bedside The further the initial error was from the bedside (and the closer it eventually got), the more processes that will need to be addressed. The closer the initial error was to the bedside, the fewer processes that will need to be addressed. However, those few processes may be tougher to find and more easily susceptible to misunderstanding and oversimplification. 6
Beware of Bad Apple Explanations The error was obvious, the person should have known better, I ll I have a talk with them It s s a performance issue. There is usually a faulty system or process underlying a seemingly poor performance. Asking Why Questions Continuous why questions can firmly move the current thinking from who screwed up? to anybody (including me) would have done the same thing. Always seek to move the inquiry from people to processes 7
Turning Continuous Why Questions into the Potential for Corrective Action Keep aware of the processes identified, distinguishing the formal from the informal Place answers and concerns in categories that deepen understanding and provide a context for action JCAHO has an inventory of such categories that they suggest be reviewed in the context of each event JCAHO Minimum Scope of Root Cause Analysis Behavioral Assessment Process Physical Assessment Process Patient Identification Process Patient Observation Procedures Care Planning Process Continuum of Care Staffing Levels Orientation & Training of Staff Competency assessment/credentialing S i i f St ff Communication with patient & family Communication among staff members Availability of information Adequacy of technological support Equipment Maintenance & Management Physical Environment Security Systems & Processes Medication Management (storage, access, labelling) 8
Staffing Not Enough People Not the Right People The People Ain t Right Not Enough People Unit staffed to: Grid Budget Acuity Absenteeism Impact of staff called away for codes or emergencies 9
Not the Right People New Staff Medical Residents Experienced Staff Covering in Unfamiliar Roles Not Prepared for Low Frequency Incidents Lack of Privileges/Credentials Casual Staff (infrequently scheduled) Fatigue The People Ain t Right Overtime Worked too many consecutive days Stress/Distractions Work Home Overload Too many patients, multitasking, preceptors, etc. 10
Communication Two Forms: Verbal & Written Frequent Problems with the interaction between the two Handoffs Links Not Established: People/Departments Don t t Know One Another Implicit Communication Indirect Communication Talking Past Each Other Role & Status Differences Training, Orientation and Perspective Differences Culture Problems with Individuals Known Policy or Procedure Directly Violated Help not Sought by Those Contributing to Error Help Not Given to Those Who Requested It Failures of Authority Concerns Raised, but Authority Did Not Follow Up Safety Checks Bypassed with Knowledge of Management Authority too Fragmented/No One in Charge Did Not Voice Concern for Fear of Retributuion 11
Culture Failure of Checks & Balances Shortcuts Taken & Not Questioned Gut Feeling Something Wrong, Didn t Say Anything Error is Consequence of a Workaround or Previous Stopgap Fix Types of Action Plans Re-emphasis emphasis of existing policies or procedures Remind, Retrain, Audit Changes in policies or procedures to improve but not standardize practice Changes to the physical environment Changes in information systems Changes in medical/clinical technology Changes in policies or procedures to accommodate changes in technology Changes in policies or procedures that standardize practice Process Redesign 12
A Successful Root Cause Analysis Completes an investigation that accommodates multiple perspectives Defines a Problem that can be solved Considers all possible causes of that problem completely and fairly Determines the cause(s) of the problem that most need to be remedied Develops corrective actions that significantly reduce the probability of recurrence 13