Presentation on theme: "WVU Dept Family Medicine-Eastern Division"— Presentation transcript:
1 WVU Dept Family Medicine-Eastern Division Root Cause AnalysisKonrad C. Nau, MDProfessor and ChairWVU Dept Family Medicine-Eastern Division
2 Objectives1) Understand importance of systems-based thinking when adverse events occur in medicine2) Learn three approaches to Root Cause Analysis3) Understand common pitfalls encountered when approaching patient safety issues
3 What is Root Cause Analysis? Process for identifying contributing/ causal factors that underlie variations in performance associated with adverse events or near-miss/close callsProcess that features interdisciplinary involvement of those closest to and/or most knowledgeable about the situation
4 Adverse and Sentinel Events “Unintended injury to patients resulting from a medical intervention, which includes any action by healthcare workers, including clerical and maintenance staff.” Institute of Medicine“An unexpected occurrence involving death or serious physical or psychological injury or risk thereof.” Joint Commission
5 Use Language <www.georgecarlin.com> Near-Miss EventsWhen two planes nearly collide, they call it a “near miss.” It’s a NEAR HIT.A collision is a “near miss.” BOOM! “Look, they nearly missed!”George CarlinThe Absurd Way WeUse Language <www.georgecarlin.com>
6 Where Did it Come From?Derivative of Failure Mode Effect Analysis (FMEA) – US Military(1949) to determine effect of system and equipment engineering failuresFMEA use by NASA for Apollo space program (1960s)US Auto Industry FMEA Standards implemented (1993)
7 Why involve residents in RCA? Residents know what happens at the microprocess levelResidents are future leaders in healthcareResidents are either team members or as implementer of key action plansResident/Fellow Participation in Patient Safety Activities - BaselineAnalysis of National RCA database (many caveats)Residents as RCA team members < 30 (< 0.1%)All physicians ~ 15%!
8 Overview of RCA Steps Charter an inter-disciplinary team (4-6 people) Those familiar and un-familiar with the processFlow diagram of “what happened?”Triggering questions to expand this viewSite visits and simulation to augmentInterviews with those involved or those with similar jobResources (articles - NPSF, online databases)Root cause/contributing factors developedFive rules of causation to guide/push the team deep enoughCause and Effect Diagram, etc
9 Five Causal Rules - Marx Rule 1 - Causal Statements must clearly show the "cause and effect" relationship.When describing why an event has occurred, you should show the link between your root cause and the bad outcomeeach link should be clear to the RCA Team and others.
10 Five Causal Rules - Marx Rule 2 - Negative descriptors (e.g., poorly, inadequate) are not used in causal statementTo force clear cause and effect descriptions (and avoid inflammatory statements), we recommend against the use of any negative descriptor that is merely the placeholder for a more accurate, clear description“The Resident Manual was poorly written” vs“OnCall start and stop times are not documented in policy”
11 Five Causal Rules - Marx Rule 3 - Each human error must have a preceding cause.It is the cause of the error, not the error itself, which leads us to productive prevention strategies.“Joe ordered heparin and the patient bled out” vs“Joe order heparin because he was unaware of a history of active Peptic Ulcer Disease in the pt.”
12 Five Causal Rules - Marx Rule 4 - Each procedural deviation must have a preceding cause.Procedural violations are like errors in that they are not directly manageable. Instead, it is the cause of the procedural violation that we can manage.
13 Five Causal Rules - Marx Rule 5 - Failure to act is only causal when there was a pre-existing duty to act.A doctor's failure to prescribe a medication can only be causal if he was required to prescribe the medication in the first place.The duty to perform may arise from standards and guidelines for practice; or other duties to provide patient care.
14 NCPS RCA ModelA rigorous,legally protected and confidential approach to answering:- What happened? (event or close call)What happened that day?What usually happens? (norms)What should have happened? (policies)- Why did it happen?- What are we going to do to preventit from happening again? (actions/outcomes)- How will we know that our actions improved patient safety? (measures/tracking)
15 Methods of RCA Questioning to the Void Event & Causal Factor Analysis Safeguard Analysis
16 Questioning to the Void A systematic approach of asking questions:How is it that?What do we know about . . .?In Japan, called the Five Whys.
17 Questioning to the Void Toyota says ask why 5 timesKeep going until your answer to why is:I don’t knowI don’t careIt fell because of gravity.Why is there gravity?(I don’t care)
22 Steps in Safeguard Analysis Identify potential or actual source of an event and identify the actual or potential victim.Identify safeguards currently in place and determine effectiveness.Develop plan to strengthen weak safeguards.Identify/deploy new safeguards.