Sorry, you need to enable JavaScript to visit this website.
Skip to main content
Study

"SWARMing" to improve patient care: a novel approach to root cause analysis.

Li J, Boulanger B, Norton J, et al. "SWARMing" to Improve Patient Care: A Novel Approach to Root Cause Analysis. Jt Comm J Qual Patient Saf. 2015;41(11):494-501.

Save
Print
November 4, 2015
Li J, Boulanger B, Norton J, et al. Jt Comm J Qual Patient Saf. 2015;41(11):494-501.
View more articles from the same authors.

Root cause analyses (RCAs) are widely employed at hospitals for exploring safety events. However, RCAs may not always be effective, and recent guidelines issued by the National Patient Safety Foundation highlighted the importance of emphasizing actions to address root causes. This study describes the development of a new rapid approach to RCAs, colloquially called "SWARMing," based on the concept of swarm intelligence. SWARMs are conducted without delays after a reported event. The process begins with a preliminary investigation into what happened and who was involved, followed by an in-person meeting with an interdisciplinary team and any staff directly involved in the event. The authors describe the key structure and steps of their SWARM program, including the focus on actions and accountability. Following the implementation of SWARMs, incident reporting increased by 52%. At the same time, the observed-to-expected mortality ratio decreased 37% from 1.2 to 0.7 across the health system, suggesting the program had a significant effect.

Save
Print
Cite
Citation

Li J, Boulanger B, Norton J, et al. "SWARMing" to Improve Patient Care: A Novel Approach to Root Cause Analysis. Jt Comm J Qual Patient Saf. 2015;41(11):494-501.

Related Resources From the Same Author(s)
Related Resources