Root Cause Analysis

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Root Cause Analysis

• Vic V. Vernenkar, D.O.
• St. Barnabas Hospital
• Department of Surgery

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JCAHO Alerts in 2001

• Patients catching on fire.
• Deaths due to mix-up of gases.
• Disease transmission through surgical
  instruments.
• Transmission of blood borne pathogens through
  needle sticks.
• Wrong side/wrong procedure/wrong person surgeries.

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All locations vulnerable

• Hospital-based ambulatory care units.
• Freestanding ambulatory care units.
• Inpatient operating rooms.
• Inpatient emergency rooms.
• In-home care.

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Complex Systems

• Testing Analysis
• Diagnosis
• Treatment
• Patient tracking
• Facility maintenance
• Equipment operation
• Controlled Substances

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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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Immediate Causes

• Deviations between what should occur and what
  actually occurred.
• The immediate cause may be disguised by
  complexity of events.
• Important to be able to ask diagnostic questions
  what, where, when, extent, is and is not.

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What is a root cause?

• A root cause is the most basic causal factor, or
  factors, which if corrected or removed will
  prevent the recurrence of a situation, such as an
  error in performing a procedure.
• Root causes create the setting for immediate
  causes of problems.
• Analysis is an investigative technique that
  allows organizations to identify retrospectively
  the reasons why certain outcomes occurred.
• Oversimplification!

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Why do root causes exist?

• Adverse and sentinel events are symptoms of a
  pathology in the organization.
• What is the disease that is eating away at the
  organization?
• A disease in an organization can cause collapse
  of multiple work systems.
• Must look at ACTIONS and CONDITIONS

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Witch Hunt

• Root cause analysis cannot be done by witch
  hunting!!
• Search out the last person, blame it on them and
  ignoring the 9-10 errors that led up to that last
  error.
• For example blaming the most junior resident.

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Root Cause Analysis

• . . . Is a questioning process.
• There are several tools that will provide
  structure to this questioning process to assist
  organizations in the examination process.

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Several Methods of Root Cause Analysis

• 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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Focused Review

• What exactly was the adverse event?
• What was the chain of events that resulted in the
  adverse event?
• Was the adverse event preventable?
• Did any errors lead to the adverse event?
• What were the root causes (indirect and direct)of
  the adverse event and each error?

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Focused Review

• Did any errors or root causes involve an
  inadequate system or a system failure?
• Do we need to redesign the system?
• Were any actions taken by staff in responding to
  the adverse event particularly helpful?
• Should any personnel actions be initiated?
• Any lessons that need to be learned?

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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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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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Hierarchy of Safeguards

• Physical
• Natural
• Information
• Measurement
• Knowledge
• Administrative

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Problems with root cause taxonomies

• Most root causes are identified as being related
  to a weakness in the management system.
• Most root cause categories do not dig deep enough.

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Taxonomy of Root Causes

• Placing budget considerations ahead of patient
  safety and quality.
• Placing schedule considerations ahead of patient
  safety and quality.
• Placing political considerations ahead of patient
  safety and quality.
• Arrogance.
• Lack of understanding, knowledge.
• Sense of entitlement among the staff.

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Pathological behaviors

• Rationalization
• Illusion of invulnerability.
• Self-censorship.
• Direct pressure on deviants.
• Breed within the organization.
• People who continue to disagree are forced out.

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Case 1

• A IV pole attached to a bed was brought to the MR
  room with a patient. The MR magnet pulled the
  pole loose from the bed. The pole flew across the
  room narrowly missing the head of the patient and
  stuck to the magnet.
• Emergent shut downs of MRIs cost 20,000-500,000
• Potential for injury high
• Its easy to blame the MRI tech here, but is there
  a system failure?

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Case 1

• For example, were training programs for staff
  designed up front with the intent of helping
  staff perform the task without errors?
• Had procedures and equipment been reviewed to
  ensure a good match between people and the tasks
  they did or people and the equipment they used?
• Were all staff trained in the use of relevant
  barriers and controls to prevent this?
• If equipment was involved, did it work smoothly
  in the context of a) staff needs and experience,
  b) existing procedures, requirements, and
  workload and c) physical space and location?

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Case 2

• A patient had become bradycardic because of
  medication and the cardiac process. It was
  determined that an intravenous pacemaker was
  needed quickly, and one was brought to the
  bedside. When the pacemaker was turned on, an
  error message appeared, making it impossible to
  use the pacemaker on the patient. A different
  pacemaker of the same make was found and the
  patient successfully paced, with no sequellae.

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Case 2

• Here the severity of the event was minor, but the
  potential systems implication was catastrophic
  because a spare pacemaker may not always be
  available.
• When root cause was performed, it was noted that
  there was not adequate training of staff on how
  to deal with the error message, furthermore due
  to time restraints on the staff, the 200 page
  manual was not read. The companys trouble
  shooting card did not include the error message
  on it, resulting in the error codes first
  appearance in critical use for a patient.

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Undesirable outcomes
Great Outcomes
Remedy the present situation
Identify better practices
Do the Root Cause Analysis
Prevent Future happenings
Establish a portfolio of better practices
Pave the way for evidence based practices
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Summary

• Incident analysis, properly understood, is really
  not a retrospective search for root causes but
  should be an attempt to look to the future.
• In a sense, the particular causes of the incident
  do not matter as they are now in the past.
  However, the weaknesses of the system revealed
  are still present and could lead to the next
  incident.

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References

• Diagnosing and Preventing Adverse and Sentinel
  Events. John Dew and Meri Curtis. Opus
  Communications, 2001.
• Sentinel Events Evaluating Cause and Planning
  Improvement. Joint Commission on Accreditation of
  Health Care Organizations. 1998.