Root Cause Analysis
Background
Root cause analysis (RCA) is a structured method used to analyze serious adverse events. Initially developed to analyze industrial accidents, RCA is nowwidely 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. RCA thus uses the systems approach 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). It is one of the most widely used retrospective methods for detecting safety hazards.
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.
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 2009, 25 states and the District of Columbia 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.
Root cause analysis (RCA) is a structured method used to analyze serious adverse events. Initially developed to analyze industrial accidents, RCA is nowwidely 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. RCA thus uses the systems approach 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). It is one of the most widely used retrospective methods for detecting safety hazards.
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 2009, 25 states and the District of Columbia 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
STUDY
Development and validation of a taxonomy of adverse handover events in hospital settings.
Andersen HB, Siemsen IMD, Petersen LF, Nielsen J, Østergaard D. Cogn Technol Work. 2015;17:79-87.
COMMENTARY
Root cause analysis to support infection control in healthcare premises.
Venier AG. J Hosp Infect. 2014 Dec 30; [Epub ahead of print].
STUDY
Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance.
Chassin MR, Mayer C, Nether K. Jt Comm J Qual Patient Saf. 2015;41:4-12.
COMMENTARY
A method for prioritizing interventions following root cause analysis (RCA): lessons from philosophy.
Boyd M. J Eval Clin Pract. 2014 Nov 13; [Epub ahead of print].
COMMENTARY
Rethinking diagnostic delay in cancer: how difficult is the diagnosis?
Lyratzopoulos G, Wardle J, Rubin G. BMJ. 2014;349:g7400.
Development and validation of a taxonomy of adverse handover events in hospital settings.
Andersen HB, Siemsen IMD, Petersen LF, Nielsen J, Østergaard D. Cogn Technol Work. 2015;17:79-87.
Root cause analysis to support infection control in healthcare premises.
Venier AG. J Hosp Infect. 2014 Dec 30; [Epub ahead of print].
Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance.
Chassin MR, Mayer C, Nether K. Jt Comm J Qual Patient Saf. 2015;41:4-12.
A method for prioritizing interventions following root cause analysis (RCA): lessons from philosophy.
Boyd M. J Eval Clin Pract. 2014 Nov 13; [Epub ahead of print].
Rethinking diagnostic delay in cancer: how difficult is the diagnosis?
Lyratzopoulos G, Wardle J, Rubin G. BMJ. 2014;349:g7400.
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
In Conversation with...Albert Wu, MD, MPH.
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
Patrice Spath, BA, RHIT, and William Minogue, MD. AHRQ WebM&M [serial online]. July 2008
AHRQ WebM&M [serial online]. July 2008
Jill Rosenthal, MPH. AHRQ WebM&M [serial online]. June 2007
Scott A. Flanders, MD; Sanjay Saint, MD, MPH. AHRQ WebM&M [serial online]. June 2005
Serious Reportable Events in Healthcare—2011 Update.Washington, DC: National Quality Forum; 2011. ISBN: 9780982842188.
Percarpio KB, Watts V. Jt Comm J Qual Patient Saf. 2013;39:32-37.
Shaping systems for better behavioral choices: lessons learned from a fatal medication error.Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.
Effectiveness and efficiency of root cause analysis in medicine.Wu AW, Lipshutz AKM, Pronovost PJ. JAMA. 2008;299:685-687.
The investigation and analysis of critical incidents and adverse events in healthcare.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.Bagian JP, Gosbee J, Lee CZ, Williams L, McKnight SD, Mannos DM. Jt Comm J Qual Improv. 2002;28:531-545.
The wrong patient.Chassin MR, Becher EC. Ann Intern Med. 2002;136:826-833.
Department of Veterans Affairs (VA), PO Box 486, Ann Arbor, MI 48106-0486.
Sentinel Event.The Joint Commission.
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