Root cause analysis (RCA) is a common approach to adverse event investigation in hospitals. Small teams of clinicians and managers invest many hours in making sense of serious adverse events in their facility. Yet the final report produced as the main output of an RCA may be limited in its capture of the team's view and when fed back to the clinical area where an event took place, the event described in the RCA report is unrecognisable.
Hi Bryce I have just done a critical analysis on 87 babies being born in poor condition or death. Some thoughts for you. One of the key findings is that the report is always done in retrospect of course, There are several things here: one is that the outcome is already known, so the questions are geared for hindsight bias to be prevalent; two that there has been time for the HCP (sometimes weeks or months in some of the obstetric cases) before an RCA is completed and therefore there is no control about intercommunication with other members of the team or cognitive distortion; three depends on the culture of the organisation, is it blame and shame looking for a scapegoat or is it learning from events; four because the event has already happened and actions are taken, yet another checklist is often put into place until there are checklists for checklists in some extremes; five I have found in this very in-depth and lengthy analysis that the conclusions always seem to be: more training, time of day, busy workload and poor communication are the key causes (consistent over a period of 10 years). So with all the extra training, communication practices etc that are put into place, adverse events are still not partialed out. Another key finding was that the investigation is often very top down and that brings with it often a lot of extraneous variables in the feedback processes.
It goes without saying that the way things are worded are key here and how the information is gathered whether it is at a formal meeting or informal chat and by whom.
Cheers
Sharon
Sharon, thanks for the reply.
Do you have a reference for the work above as I think the general findings will be useful in some of the work I am doing?
Thanks
Gareth
Hi Bryce
Several Setinel events using RCA technique've analyzed And achieved good results, I think the use of this method is useful in the hospital about Setinel event.
- Badges
- Science topic
- Similar topics
- Chemistry
- Pharmacology
- Pharmaceuticals
- Drugs