Why Incident Investigations Fail to Improve Patient Safety
The article I selected this week discussed the importance of root-cause analysis for improving patient care. It is recommended that organizations should not look at the next quality improvement issue until the one they are working on is complete. Hospitals have been performing root-cause analysis for more than 10 years, but they continue to experience repeat incident. This is probably due to the fact that the original incident was not properly addressed.
Many people today think that we should stop using root-cause analysis and find a method that guarantees success. I think instead of finding a different method, hospitals should take the responsibility of addressing the original problems that limit the importance of incident investigations. This article made several recommendations that should help improve the outcomes of performing root-cause analysis. They include:
* Find and resolve latent conditions as well as root cause
* Treat the cause rather than try to change people
* Get rid of the “Oh wells”
One example in the article, mentioned the 2003 Columbia Space Shuttle disaster and how the investigation did not end at root-cause analysis. The investigators continued to ask “Why”, which lead to the underlying reason for the disaster being exposed. I think it is sad that the reason for this tragedy was due to schedule pressures; and, the staff at NASA disregarded concerns and continued with the launch. In this situation, root-cause analysis would be a valuable tool to help prevent this from occurring in the future.
Another interesting point in the article was to perform process redesign instead of changing people’s behavior through interventions such as retraining or memory aids. It is human nature to blame someone else for your mistake, but it is about time that people in the healthcare field start owning up to their mistakes. If someone realizes the potential for harm they should work to redesign the process so that the possible incident will not occur again. It is our responsibility to speak up in order to protect patients. The article suggested using rapid-cycle PDSA, which stands for Plan, Do, Study, Act. I had never heard of this process, but it is used to perform tests on process redesign to allow the organization to respond immediately if safety interventions do not work out.
As I stated before, I think the solution is not to find a new technique for improving quality and safety, but make the current approach more successful.
Quality Tool- VA National Center for Patient Safety: Root- Cause Analysis
Root-Cause Analysis a tool used to identify prevention strategies in order to build a safe environment and move beyond the culture of blame. This quality tool identified several goals of root-cause analysis. To discover:
* What happened?
* Why did it happen?
* What to do to prevent it from happening again
I am not going to go into the steps of root-cause analysis because we have already studied this in Ms. Morey’s class. However, I am going to point out some tips to be more thorough when performing root-cause analysis. To be thorough, a root-cause analysis must include:
* Determination of human and other factors
* Determination of related processes and systems
* Identifications of risks and their potential contributions
* Determination of potential improvement opportunities in processes or systems
It is easy to forget about quality when you are performing the same tasks daily. That is why this tool is used to discover hidden faults in a process to enable us to correct them. I thought it was interesting that in order for a root-cause to be credible, it should be internally consistent and include consideration of relevant literature. It is also helpful to have the participation of upper management. It is important that they know what is going on in their facility, both good and bad.
http://www.patientsafety.gov/rca.html
Classmate Pick of the Week- Ramona’s Blog
This week I read Ramona’s blog discussing the opportunities for improvement. I agree with her regarding the doctor’s office at being the primary source of healthcare. In today’s society, it is hard for people with insurance to pay for medical bills, so imagine the stress and burden the uninsured experience. Before I came to UMMC, I was one of those that was stressed and burdened by the astronomical cost for healthcare. There should be improvements made to enable to same quality of healthcare at a reasonable cost. Ramona’s point about the patient feeling they got a “raw deal” is true. Often, patients leave their PCP without answers.
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