Building Patient Safety Skills

Building Patient Safety Skills
Common pitfalls when conducting a root cause analysis

From the April 22, 2010 issue

Most hospitals are acquainted with the root cause analysis (RCA) process and have conducted numerous RCAs in the past 15 years since The Joint Commission first required its use to investigate sentinel events. RCA is the most basic type of event investigation; an analytical approach to problem solving that seeks to identify why adverse events happen and how to prevent them.

Through our consultation services, ISMP has had an opportunity to review many RCAs associated with medication-related events. While we have seen a steady rise in the use of this tool, we continue to observe common pitfalls encountered while conducting a RCA, often rendering the process less useful than intended.

These pitfalls are not surprising given the lack of well-designed patient safety and quality improvement curricula available to healthcare professionals during their training and post-graduation. Many healthcare professionals learn the science and skills associated with quality improvement and patient safety—including RCA—through informal on-the-job training (although workshops on these topics have been available periodically). Most would agree that not enough has been done to prepare healthcare professionals to anticipate, identify, analyze, and resolve patient safety problems.

ISMP plans to present a series of articles on event investigation, data analysis, and prospective risk-assessment that will be published periodically during 2010. Skills in these areas are pivotal to patient safety and quality improvement. We begin this week with a discussion about pitfalls ISMP commonly observes with RCA.

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Building Patient Safety Skills