How does learning occur from adverse events, near misses, and errors?
One method is through root cause analysis (RCA). RCA is a systematic process in which adverse events and near misses are investigated. This approach came from high-risk industries such as nuclear power and aviation and was modified for health care as the patient safety movement began in the late 1990s.
RCA takes an organized, systems approach to determine what happened and why the event occurred (root cause). Moving forward, a corrective action plan is developed to prevent it from happening again in the future. The standard process involves interviewing staff, forming a timeline of events, and determining if any gaps in care or opportunities for improvement exist. There is a comparison of what happened versus what is supposed to happen.
Gaps or opportunities are identified by comparing to the standard of care, hospital guidelines, and best practices. In order to determine root causes, using a 5 why the approach is used, in which the investigator continues to ask why the gap occurred five times to enable reaching the primary root cause. Often, multiple root causes and corrective actions are identified. Examples of root causes include culture (i.e. lack of culture empowering staff to speak up when concerned) or process (i.e. lack of a standardized process of physician coverage).
Corrective action plans could include drafting new guidelines, staff education, or adopting new processes. Accrediting bodies and some state regulatory agencies mandate RCAs after sentinel events and when significant patient harm occurs.
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Gupta, K., Sarkar, U., & Lyndon, A. (n.d.). Rethinking Root Cause Analysis. Retrieved from https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis