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Initially developed Scholary anaylsis analyze industrial accidents, RCA is now widely 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 Scholary anaylsis 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. 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. The hospital was under regulatory pressure to improve its pneumococcal vaccination rates.
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.
The patient experienced an opiate overdose and aspiration pneumonia, resulting in a prolonged ICU course.
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.
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. A commentary identified eight common reasons why root cause analyses fail to result in improved safety, including overreliance on weak solutions such as educational interventions and enforcing existing policiesfailure to aggregate data across institutions, and failure to incorporate principles of human factors engineering and safety science into error analysis and improvement efforts.
The National Patient Safety Foundation has proposed renaming the process root cause analysis and action RCA2 to ensure that efforts will result in the implementation of sustainable systems-based improvements.
A Annual Perspective discusses the limitations of the current approach to RCA and how the process can be made more effective. As of27 states and the District of Columbia have mandated reporting of serious adverse events increasingly using the National Quality Forum's list of Never Eventsand many states also require that RCA be performed and reported after any serious event.
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