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Root Cause Analysis
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Background

Root cause analysis (RCA) is a structured method used to analyze serious adverse events. Initially developed to analyze industrial accidents, RCA is now widely deployed as an error analysis tool in health care. A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals. The goal of RCA is thus to identify both active errors (errors occurring at the point of interface between humans and a complex system) and latent errors (the hidden problems within health care systems that contribute to adverse events).

RCAs should generally follow a prespecified protocol that begins with data collection and reconstruction of the event in question through record review and participant interviews. A multidisciplinary team should then analyze the sequence of events leading to the error, with the goals of identifying how the event occurred (through identification of active errors) and why the event occurred (through systematic identification and analysis of latent errors) (Table). The ultimate goal of RCA, of course, is to prevent future harm by eliminating the latent errors that so often underlie adverse events.

Table. Factors That May Lead to Latent Errors

Type of Factor

Example

Institutional/regulatory

A patient on anticoagulants received an intramuscular pneumococcal vaccination, resulting in a hematoma and prolonged hospitalization. The hospital was under regulatory pressure to improve its pneumococcal vaccination rates.

Organizational/management

A nurse detected a medication error, but the physician discouraged her from reporting it.

Work environment

Lacking the appropriate equipment to perform hysteroscopy, operating room staff improvised using equipment from other sets. During the procedure, the patient suffered an air embolism.

Team environment

A surgeon completed an operation despite being informed by a nurse and the anesthesiologist that the suction catheter tip was missing. The tip was subsequently found inside the patient, requiring reoperation.

Staffing

An overworked nurse mistakenly administered insulin instead of an antinausea medication, resulting in hypoglycemic coma.

Task-related

An intern incorrectly calculated the equivalent dose of long-acting MS Contin for a patient who had been receiving Vicodin. The patient experienced an opiate overdose and aspiration pneumonia, resulting in a prolonged ICU course.

Patient characteristics

The parents of a young boy misread the instructions on a bottle of acetaminophen, causing their child to experience liver damage.


As an example, a classic paper described a patient who underwent a cardiac procedure intended for another, similarly named patient. A traditional analysis might have focused on assigning individual blame, perhaps to the nurse who sent the patient for the procedure despite the lack of a consent form. However, the subsequent RCA revealed 17 distinct errors ranging from organizational factors (the cardiology department used a homegrown, error-prone scheduling system that identified patients by name rather than by medical record number) to work environment factors (a neurosurgery resident who suspected the mistake did not challenge the cardiologists because the procedure was at a technically delicate juncture). This led the hospital to implement a series of systematic changes to reduce the likelihood of a similar error in the future.

RCA is a widely used term, but many find it misleading. As illustrated by the Swiss cheese model, multiple errors and system flaws often must intersect for a critical incident to reach the patient. Labeling one or even several of these factors as "causes" may place undue emphasis on specific "holes in the cheese" and obscure the overall relationships between different layers and other aspects of system design. Accordingly, some have suggested replacing the term "root cause analysis" with "systems analysis."

Effectiveness of Root Cause Analysis

RCA is one of the most widely used approaches to improving patient safety, but perhaps surprisingly, few data exist to support its effectiveness. As noted in a recent commentary, much of the problem lies in how RCAs are interpreted rather than in how they are performed, since there is no consensus on how hospitals should follow up or analyze RCA data. This limits the utility of RCA as a quality improvement tool. Another issue is that few formal mechanisms exist for analysis of multiple RCAs across institutions. As an individual RCA is essentially a case study of a specific error, analysis of multiple RCAs performed at different institutions may help identify patterns of error and point the way toward solutions. Some states mandate performance of an RCA for certain types of errors (including never events) and report the findings of these RCAs in aggregate. Ultimately, Patient Safety Organizations listed by AHRQ will also serve this function.

Current Context

The Joint Commission has mandated use of RCA to analyze sentinel events (such as wrong-site surgery) since 1997. As of April 2007, 26 states have mandated reporting of serious adverse events (increasingly using the National Quality Forum's list of "Never Events"), and many states also require that RCA be performed and reported after any serious event. Although no data are yet available on this subject, RCA use has likely increased with the growth in mandatory reporting systems.

 
What's New in Root Cause Analysis on AHRQ PSNet
COMMENTARY
Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia.
Tjia I, Rampersad S, Varughese A, et al. Anesth Analg. 2014;119:122-136.
STUDY
Wrong-side thoracentesis: lessons learned from root cause analysis.
Miller KE, Mims M, Paull DE, et al. JAMA Surg. 2014 Jun 11; [Epub ahead of print].
STUDY
Mind the gap between recommendation and implementation—principles and lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading to the successful implementation of recommendations.
Wrigstad J, Bergström J, Gustafson P. BMJ Open. 2014;4:e005326.
COMMENTARY
Quality and safety education for nurses: a nursing leadership skills exercise.
Harrison EM. J Nurs Educ. 2014;53:356-361.
STUDY
Root cause analysis of serious adverse events among older patients in the Veterans Health Administration.
Lee A, Mills PD, Neily J, Hemphill RR. Jt Comm J Qual Patient Saf. 2014;40:253-262.
STUDY
Root cause analysis of ambulatory adverse drug events that present to the emergency department.
Gertler SA, Coralic Z, López A, Stein JC, Sarkar U. J Patient Saf. 2014 Feb 27; [Epub ahead of print].
 
Editor's Picks for Root Cause Analysis
From AHRQ WebM&M
In Conversation with...Albert Wu, MD, MPH.
AHRQ WebM&M [serial online]. July 2008
The Soil, Not the Seed: The Real Problem with Root Cause Analysis.
Patrice Spath, BA, RHIT, and William Minogue, MD. AHRQ WebM&M [serial online]. July 2008
Advancing Patient Safety through State Reporting Systems.
Jill Rosenthal, MPH. AHRQ WebM&M [serial online]. June 2007
Getting to the Root of the Matter.
Scott A. Flanders, MD; Sanjay Saint, MD, MPH. AHRQ WebM&M [serial online]. June 2005
 
From AHRQ PSNet
JOURNAL ARTICLE
Effectiveness and efficiency of root cause analysis in medicine. Classic icon
Wu AW, Lipshutz AKM, Pronovost PJ. JAMA. 2008;299:685-687.
The investigation and analysis of critical incidents and adverse events in healthcare. Classic icon
Woloshynowych M, Rogers S, Taylor-Adams S, Vincent C. Health Technol Assess. May 2005;9:1-158.
The Veterans Affairs root cause analysis system in action. Classic icon
Bagian JP, Gosbee J, Lee CZ, Williams L, McKnight SD, Mannos DM. Jt Comm J Qual Improv. 2002;28:531-545.
The wrong patient. Classic icon
Chassin MR, Becher EC. Ann Intern Med. 2002;136:826-833.
Shaping systems for better behavioral choices: lessons learned from a fatal medication error. Classic icon
Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.
BOOK/REPORT
Serious Reportable Events in Healthcare—2011 Update. Classic icon
Washington, DC: National Quality Forum; 2011. ISBN: 9780982842188.
WEB RESOURCE
National Center for Patient Safety (NCPS).
Department of Veterans Affairs (VA), PO Box 486, Ann Arbor, MI 48106-0486.
Sentinel Event. Classic icon
The Joint Commission.
 
Last Updated: October 2012