Root Cause Analysis (RCA)
Overview and Introduction to
Team Project
25-27 June, 2009
Greg Ogrinc, MD, MS
Dartmouth Medical School
Objectives
• Meet, get to know, and work with some
colleagues from other healthcare
professions
• Understand the background and theory of
root cause analysis as a tool for
investigating medical error
• Develop one set of skills – root cause
analysis – to analyze medical errors
Agenda
1. What is a root cause analysis (RCA)?
Why is it important? (15 min)
2. Interprofessional teamwork and
communication (10 min)
3. University of Minnesota CLARION RCA
competition (5 min)
4. Mini-RCA (45 min)
5. Instructions to teams and getting started
(15 min)
Case Examples
• A young man arrives in the emergency department with chest
pain. He has no family history of heart conditions and is
outside the typical age range for heart attacks. His
electrocardiogram is normal, and he reports that he has been
moving furniture the past few days. The physician on duty
concludes that this is a muscular injury, prescribes Motrin and
rest, and discharges the patient. Unfortunately, the patient
returns several hours later with a full-blown heart attack and
in shock.
• A nurse is asked to give a patient a particular IV antibiotic.
She grabs the wrong antibiotic from the cabinet and
administers a different IV medication instead.
http://www.ihi.org/IHI/Programs/IHIOpenSchool/
Blame and Punishment…
• These are the traditional responses to error
• 5% error from incompetent or poorly intended
care
• 95% from conscientious and competent
individuals involved in circumstances that led to
a catastrophic result
• Must differentiate between unintentional
situations and deliberate ones
– Impaired by alcohol or drugs
– Criminal acts
Systems Approach to Safety
• Latent errors (after James Reason, 1990)
– defects in the design and organization of
processes and systems that can lead to
failures and errors
– often unrecognized or just become accepted
aspects of the work
Vincent, NEJM, 2003
Principles for Understanding System Failure
• Search for underlying cause
• Causes can be reasonably identified
– Not intended to be a search for buried treasure
• System causes can be modified by
leaders/managers
• Effective recommendations can be
generated
Rooney and Vanden Heuval, Qual Progress, 2004
Taxonomy and Types of Errors
• Skill-based errors – slips and lapses – when
the action made is not what was intended
• Rule-based mistakes – actions that match
intentions but do not achieve their intended
outcome due to incorrect application of a rule or
inadequacy of the plan
• Knowledge-based mistakes – actions which
are intended but do not achieve the intended
outcome due to knowledge deficits
http://patientsafetyed.duhs.duke.edu/module_e/types_errors.html
Core Concepts of Root Cause
Analysis (RCA)
• Improve rather than blame
• Attend to the emotions of all the
individuals involved
• Recognize a series of causes (not just the
proximal one)
• Look forward for improvements
– More than just an autopsy of a mistake
Root Cause Analysis
A method for identifying the basic or
contributing causal factors that underlie
variations in performance associated with
adverse events or close calls
– Interprofessional team
– Focus on systems
– Digs deep into the whats, hows, and whys of the
case
– Identify actions to prevent the error from
occurring in the future
Indications for an RCA
• A serious event that has recently occurred,
• A serious near-miss
• An event associated with a bad/potentially
bad outcome
• Negligence or criminal activity is not clear
Elements/Process of an RCA
• Team: interprofessional group of people work to
understand what happened and why
• Time: time and effort are required
• Trip: walking through the event and the physical
location of the event(s)
• Talk: conversation with those involved
• Report: Writing a summary
– What happened?
– What were the causes and vulnerabilities?
– Recommendations for changes/improvements.
RCA Basic Process
1. Data collection – The team must understand
and agree upon the events and sequence of
events that occurred
2. Causal factor charting – Begin to organize
possible causes using process modelling
3. Root cause identification – Draw conclusions,
write root cause statements
4. Recommendations – How will we prevent this
in the future? How can we monitor/measure
our progress?
RCA Process
QI staff identifies
the case
Identify actions
Case
summary
given to team
Team reviews
case with
standard
methodology
Write root
cause
statements
Gathers additional
information
(interviews, chart
review, discuss with
experts in the field)
RCA in Real Life
• Time limit of 45 days to complete
• Team members
– Chosen from many professions
– Relieved of some other duties to participate
– Not involved in the event
• RCA review and recommendations go to
the top of the organization
Patient Safety in Wales
• Improving Leadership for Quality
• Reducing Healthcare Associated
Infections
• Improving Critical Care
• Improving Medicines Management
• Reducing Surgical Complications
• Improving General Medical and Surgical
Care
Pitfalls to Avoid
• Jumping to premature solutions
• Spending too much time on what and not
enough time on the why
• Not using all the triggering questions
• Getting stuck on the “clinical” part of the
case
• Focusing on blame
• Ignoring the cost implications of your
recommendations
Interprofessional teamwork
Why is teamwork important in
healthcare?
Evidence from Surgery, Medicine, Emergency
Medicine
• Gawande – 43% adverse events from
communication failures w/ 2 or more clinicians
• Risser* – 54% of tort claims from ED due to
“teamwork failure”
• Sutcliffe – interviewed 85 medicine residents
– communication failure 70 AEs
*MedTeams Research Consortium
Medical Team Training
Rules of Conduct
•
•
•
•
•
•
•
Respect each person
Share responsibility
Criticize only ideas not people
Keep an open mind
Question and participate
Attend all meetings
Listen constructively
Two-Attempt Rule
• Goal is to assure critical information is
communicated to the right person
– 1st assertive statement
• 2nd assertive statement is made if a team
member does not respond to the first
• If no effective resolution after two attempts
– Reflect back what you hear them telling you.
– Request additional input, or, in rare cases, go
up the chain of command to express
concerns.
• Eg. If a surgeon persists in going ahead with a
case despite reservations from the circulating
nurse or anesthesiologist, call in the chief of staff
to resolve the situation
Rules of Conduct Exercise
• Think about how these rules of conduct
would work for you
• Pair- Turn to your neighbor and
• Share an example of a situation where a
rule of conduct might have helped with a
difficult situation.
– For example, one team member is continually
late to briefings or meetings. What rule would
have helped? How could you have used it to
manage that situation?
Workload Distribution
• Someone must take charge!
– Can rotate the leadership role
– Helpful to have a timekeeper (“We’ve agreed
to work together until 5:30pm, it is now
5:25pm, we should wrap up”)
• Ensure input from all members of the team
• Balance the burden of tasks to achieve
optimal outcomes
Techniques for Clear
Communication
• Read Back
– Write what you heard
– Read back what you wrote
– Confirm with the sender
• Repeat Back
– Reflect back what you hear
– Confirm with sender
CLARION
• CLARION creates and conducts co-curricular,
interprofessional experiences for U of Minnesota
Academic Health Center students
• A catalyst, inspiring faculty to reexamine
traditional curricula and seek ways to integrate
interprofessional opportunities into the education
and experience of students.
• http://www.chip.umn.edu/CHIP/committees/clario
n.html
Questions? Comments?
Agenda
1. What is a root cause analysis (RCA) and
why is it important? (15 min)
2. Interprofessional teamwork and
communication (10 min)
3. University of Minnesota CLARION RCA
competition (5 min)
4. Mini-RCA (45 min)
5. Instructions to teams and getting started
(15 min)
Mini-RCA – Part 1
•
•
Case from the VA National Center for
Patient Safety
Work in your groups
1. Read the case, agree on the facts
2. Use triage questions to determine where
you want to find more information
3. Create a list of next steps
Mini-RCA – Part 2
• You now have more information about the
case
• Review the 5 rules of causation in the RCA
triage packet
• Write one root cause statement
– Avoid negative descriptors
“The [noun or activity or lack of activity]
[increased, decreased, contributed to] the
likelihood that [name the outcome].”
Suggested RCA Statements
• “The lack of in-service training on the
monitor contributed to the likelihood that
the demo mode was not recognized.”
• “The level of clinical assessment training
increased the likelihood that the EMTs
would delay using manual, rather than
electronic, assessments.”
Instructions to the Groups
• Read the case
– Agree on the facts and the timeline of the case
• Perform a mini root cause analysis to identify
system vulnerabilities in the case
– Recommend changes to prevent this event(s) from
occurring in the future
– Include a financial assessment
• Prepare a 5 minute presentation
– Saturday afternoon, 1:15pm
– 5 PowerPoint slides or overheads
– Use the template (Show template slides)
Title
Team members (do not include
initials or professional affiliation
after your names)
Background Information
• No more than 5 or 6 bullet points, no less
than 24-point font
• Identify key structural aspects of the case
(hospital, people, mission, values)
– What is it about this institution that is
important to know and share?
Diagram of Analysis of Case
• Use a process diagram, deployment flow
diagram, or a cause and effect diagram
• Templates available on next 2 slides
• For process diagrams, use the “flowchart”
items in the “Autoshapes” menu
– These are very helpful.
– Connect boxes with “connectors” in the
“Autoshapes” menu
Cause-Effect Diagram
Use four of these terms to label the
main branches of the diagram:
People
Processes
Policy
Methods
Materials
Environmental Factors
In this box, write a focused description of
the problem under evaluation.
Root Cause Statement
• Name 1 or 2 root causes
• No blame! Focus on the system issues.
Recommendations
• 2-3 recommendations
• Be clear about what could be done to
prevent this adverse event from occurring
in the future
• Consider how you will measure whether
this is successful?
Helpful Tips…
• A cause/effect or flow diagram is a
convenient way to demonstrate “what”
– Focus on the period around the sentinel event
• You will have time to work tomorrow in
groups with feedback from faculty
• Use any resources you like
– Books, websites, local experts, etc.
• Any and all questions are welcome
– This is a learning experience…no grades!
Thanks to all…and good luck!