Outcomes analysis, quality improvement, and patient safetyInvestigating the Causes of Adverse Events
Section snippets
Identifying Causal Factors
The conceptual model for evaluating the quality of medical care, proposed by Donabedian in 1966, contains three components of medical care from which to derive information regarding quality: structure, process, and outcomes [11]. The structure of care involves the settings and context of medical care delivery. Individual processes of care—the actions and activities of delivering medical care—can be examined and compared with best known standards of practice. The processes that can readily be
Monitoring
The ideal safety-conscious clinical environment has systems in place to monitor for potential problems so that, when they occur, a prompt response can be mounted, data collected, and hazards neutralized. Protocols and procedures should be implemented to immediately respond to critical events. Crisis management algorithms and simulation exercises with frequent training are important components of risk management for a safety-focused clinical team. When accidents happen, however, this heightened
Root Cause Analysis
An RCA is a formalized, indepth process for investigating an incident with the goal of identifying the most basic factors contributing to error or poor performance. It is an impartial, interdisciplinary approach involving both individual persons uninvolved with the event as well as those who are the most familiar with the situation. By digging deeper at each level of cause and effect using an iterative and systematic approach, basic and contributing causes are surfaced with the ultimate goal of
Common Cause Analysis
RCAs are carried out in response to a single event or a cluster of events. The findings and corrective plans generated from these activities apply only to specific areas, service lines, or work teams, particularly in larger organizations [22]. Unless a higher level view is taken periodically, organizations are not able to synthesize the learning achieved from individual investigations preventing their dissemination to other areas. A “common cause analysis” aggregates the findings identified
Ending Up With a Narrow Set of Facts
Because most people are not trained to consider system failures and neglect to dig beyond proximate causes, it is easy to generate a narrow set of facts that can miss more hidden, systemic contributions to events. Investigations that consider only the actions and omissions of particular persons are incomplete and misleading. The analysis must involve a wide range of sources of information related to the processes or areas to be investigated. The absence of a wider set of inputs, particularly
The Second Victim
In the course of an incident investigation, the emotional impact on team members is quite significant and underappreciated, particularly after serious harm has occurred. Such events and errors cause increased stress, loss of confidence, guilt, anger, reduced job satisfaction, depression, and fear of potential litigation 24, 27, 28. After such an event, those health care providers at the “sharp end” are considered “second victims” (subsequent patients who are harmed by them are “third victims”)
Disclosure
Transparency and disclosure of medical errors and a strategy of prospective risk management in dealing with medical errors is vitally important in the reporting phase of an investigation and may result in a substantial reduction in medical malpractice lawsuits, lower litigation costs, and a more safety-conscious environment. In what is now referred to as communication-and-resolution programs, health systems and liability insurers have encouraged the disclosure of adverse events, proactive
Regulatory Requirements
Depending on the nature and seriousness of the event, there are duties, both from an ethical and regulatory perspective, to report certain types of events to local, state, and other regulatory agencies. This series of requirements, however, is heavily influenced by state law [34]. Currently in the United States, 26 states and the District of Columbia have reporting systems that collect information from hospitals and other facilities about adverse medical events resulting in patient death or
Conclusion
Preventable adverse events in health care are common. Understanding the systemic conditions under which errors occur is vitally important to keeping patients safe, continuous quality improvement, and sound risk management. Incident investigation and causation analysis are important components of an overall strategy to improve patient safety and reduce errors. Surgical teams and their organizations must approach the investigation of these events in a thoughtful and systematic way to understand
Recommended Resources
The Joint Commission. Root Cause Analysis in Health Care: Tools and Techniques. 5th ed. Oak Brook, IL: Joint Commission Resources; 2015.
National Patient Safety Foundation. RCA2: improving root cause analyses and actions to prevent harm. Version 2. January 2016. Available at http://www.npsf.org/?page=rca2&hhsearchterms=%22rca2%22. Accessed April 11, 2017.
VA National Center for Patient Safety. Root cause analysis (RCA) step-by-step guide. Available at //www.patientsafety.va.gov/docs/joe/rca_step_by_step_guide_2_15.pdf
References (37)
- et al.
The incidence and nature of surgical adverse events in Colorado and Utah in 1992
Surgery
(1999) - et al.
Patient safety science in cardiothoracic surgery: an overview
Ann Thorac Surg
(2016) - et al.
Using health care failure mode and effect analysis: the VA National Center for Patient Safety’s prospective risk analysis system
Joint Comm J Qual Patient Saf
(2002) - et al.
When bad things happen to good surgeons: reactions to adverse events
Surg Clin North Am
(2012) - et al.
Another surgeon’s error: must you tell the patient?
AnnThorac Surg
(2014) - et al.
Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I
N Engl J Med
(1991) - et al.
The nature of adverse events in hospitalized patients
N Engl J Med
(1991) - et al.
The Quality in Australian Health Care Study
Med J Aust
(1995) An organisation with a memory
Clin Med (Lond)
(2002)
Effectiveness and efficiency of root cause analysis in medicine
JAMA
Complications in surgery: root cause analysis and preventive measures
Plast Reconstr Surg
Root Cause Analysis in Health Care: Tools and Techniques
Donabedian's lasting framework for health care quality
N Engl J Med
Perspectives on human error: hindsight biases and local rationality
Leading organizational learning in health care
Qual Saf Health Care
Capturing, reporting, and learning from adverse events
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