Root Cause Analysis

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Root Cause Analysis

• Konrad C. Nau, MD
• Professor and Chair
• WVU Dept Family Medicine-Eastern Division

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Objectives

• 1) Understand importance of systems-based
  thinking when adverse events occur in medicine
• 2) Learn three approaches to Root Cause Analysis
• 3) Understand common pitfalls encountered when
  approaching patient safety issues

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What is Root Cause Analysis?

• Process for identifying contributing/ causal
  factors that underlie variations in performance
  associated with adverse events or near-miss/close
  calls
• Process that features interdisciplinary
  involvement of those closest to and/or most
  knowledgeable about the situation

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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

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Near-Miss Events

• When two planes nearly collide, they call it a
  near miss. Its a NEAR HIT.
• A collision is a near miss. BOOM! Look, they
  nearly missed!

George Carlin The Absurd Way We Use
Languageltwww.georgecarlin.comgt
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Where Did it Come From?

• Derivative of Failure Mode Effect Analysis (FMEA)
  US Military(1949) to determine effect of system
  and equipment engineering failures
• FMEA use by NASA for Apollo space program (1960s)
• US Auto Industry FMEA Standards implemented
  (1993)

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Why involve residents in RCA?

• Residents know what happens at the microprocess
  level
• Residents are future leaders in healthcare
• Residents are either team members or as
  implementer of key action plans
• Resident/Fellow Participation in Patient Safety
  Activities - Baseline
• Analysis of National RCA database (many caveats)
• Residents as RCA team members lt 30 (lt 0.1)
• All physicians 15!
• edward.dunn_at_med.va.gov www.patientsafety.gov

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Overview of RCA Steps

• Charter an inter-disciplinary team (4-6 people)
• Those familiar and un-familiar with the process
• Flow diagram of what happened?
• Triggering questions to expand this view
• Site visits and simulation to augment
• Interviews with those involved or those with
  similar job
• Resources (articles - NPSF, online databases)
• Root cause/contributing factors developed
• Five rules of causation to guide/push the team
  deep enough
• Cause and Effect Diagram, etc

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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 outcome
• each link should be clear to the RCA Team and
  others.

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Five Causal Rules - Marx

• Rule 2 - Negative descriptors (e.g., poorly,
  inadequate) are not used in causal statement
• To 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

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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.

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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.

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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.

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NCPS RCA Model

• A 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 prevent
• it from happening again? (actions/outcomes)
• - How will we know that our actions improved
  patient safety? (measures/tracking)

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Methods of RCA

• Questioning to the Void
• Event Causal Factor Analysis
• Safeguard Analysis

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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.

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Questioning to the Void

• Toyota says ask why 5 times
• Keep going until your answer to why is
• I dont know
• I dont care
• It fell because of gravity.
• Why is there gravity?
• (I dont care)

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Event Causal Factor Analysis
Work order written for Oxygen
Maintenance Shuts off oxygen
Staff reports Patients are Gasping.
Staff thinks oxygen cut off
Valves not Labeled
Wrong Valve Closed
Staff not briefed
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The Bidirectional RCA Process

• Work backward chronologically from event to see
  what happened
• Work forward chronologically to clarify and learn
  (Paradies)

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Cause and effect are same thing
A continuum of causes
Gano
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Safeguard Analysis
SOURCE
VICTIM
SAFEGUARDS
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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.

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