Root cause analysis in healthcare arms reliability. This page forms part of a resource on medication related patient safety alerts issued by the national patient safety agency npsa between 2002 and 2012 more. Root cause analysis training for healthcare professionals covers the concepts and rationale behind root cause analysis rca methodology, as well as tools, techniques, and the strategies should be applied in order to execute an effective root cause analysis process. A cause map, a visual root cause analysis, can be built to better understand this issue. Health care professionals use taproot root cause analysis to. This document answers questions integral to patient safety and the root cause analysis process including how to. The reason for the additional qualifier was to limit the search to use for patient safety events and not for the global use of root cause analysis.
Triage adverse events and close callsnear misses identify the appropriate rca2 team size and membership. Conducting a root cause analysis rca is a critical aspect in the process of. Root cause analysis training investigation process and. Taproot reporting is accepted by the joint commission. Patient safety and quality improvement agency for health. The national patient safety agency npsa website has now been archived. National patient safety agency 2015 organisation patient safety incident reports data workbooks september 2015. We proactively improved medication administration by combining taproot with fmea. As a consequence, she was a contributor to the design of the national patient safety agency s root cause analysis approach and toolkit.
The national patient safety agency npsa developed a set of root cause analysis guidelines and instruction documents which were taken over by the nhs commissioning board special health authority in. The rca technique originated in the engineering industry as a method of identifying latent systemsbased issues that contributed to underperformance, variations or design failures in. Older patients and falls in hospital frances healey. This is now in its 3rd edition and is in use as the rca manual across many authorities within the nhs. Root cause analysis is a tool that can be used when determining how and why a patient safety incident has occurred.
Root cause effect on patient resident recommendation action to address root cause level for action. Incidents that usually require a root cause analysis include the unexpected death of a patient, serious pressure ulcers, falls that result in injury, and some infections and medication errors. Thus, significant or pivotal means that there was significant potential for harm or actual harm, but also that the event has the potential to reveal important hazards in the organization. Despite the limitations of the rca evidence base, healthcare authorities and decision makers in nhs scotland similar to those internationally have invested heavily in developing. How to undertake a root cause analysis investigation to. The former is the expert on how to conduct a root cause analysis, while the team leader focuses on the content. Root cause analysis training for healthcare professionals course description. Root cause analysis rca is an analysis framework used in health care to determine the systemic causes and prevent recurrences of adverse events. The institute of medicines report to err is human described the alarming prevalence of medical errors and recommended a range of activities to improve patient safety. Root cause analysis rca is a systematic approach to investigations, and is applied in many healthcare settings within comprehensive patient safety systems.
The national patient safety foundation has proposed renaming the process root cause analysis and action rca2emphasizing that a. Concise incident analysis tool canadian patient safety institute. Learning from high risk industries may not be straightforward. Join us as we help to bring together and engage healthcare professionals and patients to make care safer. Sep 21, 2016 providing quality patient care is a basic tenant of medical and surgical practice. On saturday evening, february 22, 2014, 1 person died and 27 others were hospitalized due to carbon monoxide poisoning. The mha keystone center pso works with members to adopt a strong cultural stance on patient safety by emphasizing the importance of improvement at the organizational and unit level. Given the complexity of the healthcare environment. Multidisciplinary rca teams investigate matters ranging from medication errors, to suicides, to wrong site surgeries. The national patient safety agency npsa in england and wales commissioned a survey evaluation of its national training programme which consisted of 3day workshops and internet support materials.
This allows the analyst or analyzing team to identify the exact issue, identify the reason for the problem s occurrence, and to develop means to prevent the issue from recurring or reduce the probability that it will happen again. How to perform a root cause analysis for workup and future. Framework for conducting a root cause analysis and action plan, joint commission a framework for a root cause analysis and action plan in response to a sentinel event. Details of our current reporting and alerting functions can be found below. Nhs scotland organisational impact evaluation study. Root cause analysis ahrq digital healthcare research. Staff to patient and patient to staff patient engagement with services staff to family and family to staff patient to patient family to patient or patient to family family to family siblings, parents, children staff factors components physical issues poor general health e. Root cause analysis framework fraser health medical staff. The process of root cause analysis was taken from national patient safety agency framework. Root cause analysis rca is a structured approach to the investigation of patient safety incidents that is commonly applied in many modern health systems worldwide, particularly in acute hospital settings. Survey evaluation of the national patient safety agencys. In this case, the safety goal is impacted because 68 cases of illness have been reported. Patient safety essentials toolkit download these nine essential tools to guide your organization in improving patient safety and delivering safe, reliable care. She is a registered nurse and has held various posts in nursing, research and management within the national health service nhs and department of health england.
However, a followup survey several months later revealed that organizational barriers frequently limited the implementation and dissemination of rca results. This document provides guide ines for what might be considered appropriate. In 2002, maria wrote and published the textbook, six steps to rca. Root cause analysis and patient safety interventions interview. Root cause analysis training for healthcare professionals. A guide for conducting a food safety root cause analysis. Root cause analysis and failure mode and effects analysis are a required by the medicare conditions of participation b strategies for reducing wasteful process steps c patient safety improvement techniques d tools for monitoring staff performance. Multiple orthopaedic programs, including the patient safety committee of the american academy of orthopaedic surgeons aaos, have been implemented to measure quality of surgical care, as well as reduce the incidence of medical errors. Fluorouracil incident root cause analysis report 2 the institute for safe medication practices canada ismp canada is an independent national notforprofit agency committed to the advancement of medication safety in all health. Root cause analysis for tissue viability incidents. Grayson, a computer specialist at ncps, leads technical development of root cause analysis software. The joint commission on accreditation of health care organizations.
Participants at a meeting on root cause analysis held at the pew charitable trusts in october 2016 developed and agreed upon this definition. Appendix c triage and triggering questions for root cause analysis. Root cause analysis is a systematic, detailed method for determining the causes underlying an unwanted event1,2. The national patient safety foundation makes a number of key recommendations for improving the effectiveness of the rca2, includ. Improving root cause analyses and actions to prevent. The national patient safety improvement programmes sips collectively form the largest safety initiative in the history of the nhs. This group suggests appointing both a root cause analysis facilitator and a separate team leader. Triage adverse events and close callsnear misses identify. Training health care professionals in root cause analysis.
Improving root cause analyses and actions to prevent harm. Concise incident analysis tool canadian patient safety. Structured root cause analysis rca has become a recent area of interest and. Ihi does not endorse any software or training for the rca2 process that is not directly provided by ihi. Patient safetyincorporating drawing software into root cause analysis software linda williams, rn, msi, diana grayson, and john gosbee, md, ms affiliations of the authors. Aims software tool to consistently capture information. Quality improvement essentials toolkit ihi institute for. Root cause analysis training investigation process and practical application. The first step in the cause mapping process is to fill in an outline with the basic background information, including how the issue impacts the overall goals. A root cause analysis rca is a systematic and robust way of examining causal factors in any significant adverse event.
Conducting a root cause analysis rca is a critical aspect in the process of improving patient safety. National patient safety agency npsa root cause analysis toolkit. Developing a tool for assessing competency in root cause. Largescale survey of reporting culture and behaviour in all major health boards. Root cause analysis in health care joint commission resources. A matrix of human factors principles that, when applied during a root cause analysis, can help your team identify strong strategies to improve patient safety. Hospitals with a datix system could electronically upload data to the nrls, recalls jonathan hazan, chief executive of datix.
We can look at the beginnings of what such an investigation would look like in a root cause analysis. National patient safety agency national reporting and learning service root cause analysis investigation tools. Effect size of contributory factors on adverse events. National patient safety agency, primary care and specialist programmes team, national reporting and learning service human factors lead maternity cover 6 months january 2008 july 2009 nhs afc band 8a. Past npsa alerts and guidance remain available on the archived website but please use these materials with caution. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. Patient safety and infection control are not optional. Examples of approaches adapted from other industries include root cause analysis of safety incidents, which is now widely used in healthcare. Because she is a young, healthy woman with no medical problems and this was a very unexpected outcome, the charge nurse convenes a team to conduct a root cause analysis. The individuals were exposed to high levels of carbon monoxide that had built up in the basement of a restaurant.
The authors recognize and appreciate that there are many ways to define root cause analysis. It is required by the joint commission for reported events and by the department of veterans affairs va national center for patient safety for qualifying events in va medical centers. After the abolition of the national patient safety agency. A cognitive interview is an interviewing technique based on psychological theory and research for examining the retrieval of information from memory. Root cause analysis rca is a widely used method deployed following adverse events in health care. Investigation of factors affecting patient mismatching. Tools include fmea, sbar, root cause analysis, daily huddles, and more. We calculated descriptive statistics to determine the frequency distribution of contributory factors on each adverse event. Using a range of informationgathering and analytical tools such as interviews, the five whys technique, fishbone diagrams, change analysis, and others, rca seeks to understand what happened and why and to identify how to prevent future. The rca technique originated in the engineering industry as a method of identifying latent systemsbased issues that contributed to underperformance, variations or design. Root cause analysis toolkit oregon patient safety commission. Learning from patient safety incidents nhs improvement. National patient safety agency concise investigation report template author. A crosssectional study on the relationship between utilization of root cause analysis and patient safety at 9 department of veterans affairs medical centers.
The purpose of this toolkit is to support the delivery of the getting to the root of the problem root cause analysis presentation at the partners in patient safety conference 200910. Root cause analysis rca investigations of patient safety incidents1. The national nhs patient safety team is now part of nhs improvement. Root cause analysis rca is a process widely used by health professionals to learn how and why errors occurred, but there have been inconsistencies in the success of these initiatives. With increasing emphasis on patient safety quality improvement, health care systems are mirroring industry in the implementation of root cause analysis rca for the identification and mitigation o.
Root cause analysis gone wrong agency for healthcare. To see the root cause analysis investigation, click on download pdf above. Error and root cause analysis bja education oxford academic. Formal root cause analysis rca training conducted by the united kingdoms national patient safety agency improved participants understanding of how to properly conduct an rca. Root cause analysis, patient safety, tissue viability, adverse event references 1. Adverse events resources washington state department of. Research shows that systems failures are the root cause of the majority of safety incidents.
Root cause analysis rca is a process widely used by health professionals. Root cause analysis and action plan the joint commission. Root causes are identifiable and can usually be eliminated or controlled. Oct, 2014 the search in pubmed began with the use of the terms root cause analysis with an additional set of qualifying terms connected through the boolean and patient safety. Incidents that usually require a root cause analysis include the unexpected death of a patient. The second, and more critical step, is implementing actions to address unsafe conditions and prevent their future occurrence. Root cause analysis institute for healthcare quality improvement. We use a multidisciplinary team approach, known as root cause analysis rca to study health carerelated adverse events and close calls.
Report for the national patient safety agency summary of findings from the root cause analysis of 37 adverse events and near misses in obstetrics from research carried out at 7 maternity units in the north west of england brenda ashcroft. Avoiding pressure ulcers from plaster casts nursing times. They support a culture of safety, continuous learning and sustainable improvement across the healthcare system. Patient safetyincorporating drawing software into root cause. Oct, 2014 in 2003, britains national patient safety agency npsa set up a central database, the national reporting and learning system nrls, for the reporting of all patient safety incidents. This rigorous methodology is designed to ensure that all relevant aspects of an incident are understood and that effective actions are taken to reduce the risk of recurrence.
The department of veterans affairs national center for patient safety. National patient safety agency 2009 pressure ulcers under plaster casts. Root cause analysis rca originated in the manufacturing engineering sector but has been adapted for routine use in healthcare to investigate patient safety incidents and facilitate organizational learning. Any adverse event that occurs during patient care or patient death is investigated by the national naval medical center. Department of veteran affairs national center for patient safety developed a simplified version of fmea to apply to health care, called healthcare fmea hfmea.
Review of medical errors in laboratory diagnostics and where. Participate in unit patient safety evaluations and interact with staff. The goal of a root cause analysis is to identify a problem s origin by following a series of steps. They are used in many settings, including health services, to increase understanding of why an event occurred and promoting learning, without apportioning blame. Data collection data analysis facilitated by a variety of charting tools. To provide a standardized approach to the retrospective analysis of critical incidents and nearmiss events in health care, ismp canada, saskatchewan health, and the canadian patient safety institute worked together to develop a canadian root cause analysis framework. For example, medical risk management associates mrma, llc, offers software, training, and consultation to assist in risk management. This concept is best understood in the context of the type of investigation that follows, which is very much in the style of root cause analysis. Root cause analysis in tissue viability root cause analysis for tissue viability incidents frances healey patient safety manager npsa, north and east yorkshire and north lincolnshire key words.
Root cause analysis national center for patient safety veterans. Over a quarter of a million falls are reported by the uk hospitals each year, predominantly harming older patients whose vulnerability to falling arises from a complex interaction of risk factors, including impaired mobility, dementia, delirium, medication and the effects of long term and acute illness. The berwick report stated as its main objective regarding patient safety, a promise to learna commitment to act. This study was conducted in a tertiary care teaching hospital in 2014. The national patient safety agency has developed the incident decision tree to help national health service nhs managers in the united kingdom determine a fair and consistent course of action toward staff involved in patient safety incidents. Unintended retention of surgical sponge pdf example. As the rca for this case begins, the team struggles with identification of the root causes of the outcome. This article uses the stages of the national patient safety agency n. The national patient safety agency npsa developed a set of root cause analysis guidelines and instruction documents which were taken over by the nhs commissioning board special health authority in 2012. Root cause analysis for clostridium difficile infections. How to undertake a root cause analysis investigation to improve. In order to reflect the importance of this step, the national patient safety foundation has renamed the process rca squared rca 2 or root cause analysis and action national patient safety foundation, 2016. Identifying and addressing dysfunctional systems is, therefore, the key to reducing future risk of harm for many nhs patients and is the ethos behind the new national system for reporting adverse incidents that will be run by the national patient safety agency.
Error and root cause analysis bja education oxford. Root cause analysis rca investigations of patient safety incidents1 have played an important role in improving care. The national patient safety agency npsa in england and wales commissioned a survey evaluation of its national training programme which consisted of 3day. Nhs nursing and medical staff who shared their experiences in the interviews and focus groups nhs risk managers who shared anonymised root cause analysis. Root cause analysis va national center for patient safety. The national patient safety agency npsa would like to thank all the organisations and individuals who have made this report possible. The mha keystone center is recognized as a federallylisted patient safety organization pso by the agency for healthcare research and quality ahrq. Getting to the root of the problem how can root cause analysis help. As the nations patient safety agency, ahrq is observing patient safety awareness week march 814 to increase awareness about patient safety among health professionals, patients, and families.