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PSNet: Patient Safety Network
Journal Article

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

Li J, Boulanger B, Norton J, et al. Joint Commission journal on quality and patient safety. 2015;41:494-501.

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.