Managing the scope and impact of root cause analysis recommendations

What can Safety Cases offer for patient safety? A multisite case study

BACKGROUND

The Safety Case is a regulatory technique that requires organisations to demonstrate to regulators that they have systematically identified hazards in their systems and reduced risks to being as low as reasonably practicable. It is used in several high-risk sectors, but only in a very limited way in healthcare. We examined the first documented attempt to apply the Safety Case methodology to clinical pathways.

METHODS

Data are drawn from a mixed-methods evaluation of the Safer Clinical Systems programme. The development of a Safety Case for a defined clinical pathway was a centrepiece of the programme. We base our analysis on 143 interviews covering all aspects of the programme and on analysis of 13 Safety Cases produced by clinical teams.

RESULTS

The principles behind a proactive, systematic approach to identifying and controlling risk that could be curated in a single document were broadly welcomed by participants, but was not straightforward to deliver. Compiling Safety Cases helped teams to identify safety hazards in clinical pathways, some of which had been previously occluded. However, the work of compiling Safety Cases was demanding of scarce skill and resource. Not all problems identified through proactive methods were tractable to the efforts of front-line staff. Some persistent hazards, originating from institutional and organisational vulnerabilities, appeared also to be out of the scope of control of even the board level of organisations. A particular dilemma for organisational senior leadership was whether to prioritise fixing the risks proactively identified in Safety Cases over other pressing issues, including those that had already resulted in harm.

CONCLUSIONS

The Safety Case approach was recognised by those involved in the Safer Clinical Systems programme as having potential value. However, it is also fraught with challenge, highlighting the limitations of efforts to transfer safety management practices to healthcare from other sectors.

The process and perspective of serious incident investigations in adult community mental health services: integrative review and synthesis

AIMS AND METHOD

Serious incident management and organisational learning are international patient safety priorities. Little is known about the quality of suicide investigations and, in turn, the potential for organisational learning. Suicide risk assessment is acknowledged as a complex phenomenon, particularly in the context of adult community mental health services. Root cause analysis (RCA) is the dominant investigative approach, although the evidence base underpinning RCA is contested, with little attention paid to the patient in context and their cumulative risk over time.

RESULTS

Recent literature proposes a safety-II approach in response to the limitations of RCA. The importance of applying these approaches within a mental healthcare system that advocates a zero suicide framework, grounded in a restorative just culture, is highlighted.

CLINICAL IMPLICATIONS

Although integrative reviews and syntheses have clear methodological limitations, this approach facilitates the management of a disparate body of work to advance a critical understanding of patient safety in adult community mental healthcare.

What are the experiences of team members involved in root cause analysis? A qualitative study

BACKGROUND

Conducting root cause analysis (RCA) is complex and challenging. The aim of this study was to better understand the experiences of RCA team members and how they value their involvement in the RCA to inform future recruitment, conduct and implementation of RCA findings into clinical practice.

METHODS

The study was set in a health network in Adelaide, South Australia. A qualitative exploratory descriptive approach was undertaken to provide an in-depth understanding of team member's experience in participating in an RCA. Eight of 27 RCA team members who conducted RCAs in the preceding 3-year period were included in one of three semi-structured focus groups. Thematic analysis was used to synthesise the transcribed data into themes.

RESULTS

We derived four major themes: Experiences and perceptions of the RCA team, Limitations of RCA recommendations, Facilitators and barriers to conducting an RCA, and Supporting colleagues involved in the adverse event. Participants' mixed experience of RCAs ranged from enjoyment and the perception of worth and value to concerns about workload and lack of impact. Legislative privilege protecting RCAs from disclosure was both a facilitator and a barrier. Concern and a desire to better support their colleagues was widely reported.

CONCLUSIONS

Clinicians perceived value in reviewing significant adverse events. Improvements can be made in sharing learnings to make effective improvements in health care. We have proposed a process to better support interviewees and strengthen post interview follow up.

Epistemic Injustice in Incident Investigations: A Qualitative Study

Serious incident investigations-often conducted by means of Root Cause Analysis methodologies-are increasingly seen as platforms to learn from multiple perspectives and experiences: professionals, patients and their families alike. Underlying this principle of inclusiveness is the idea that healthcare staff and service users hold unique and valuable knowledge that can inform learning, as well as the notion that learning is a social process that involves people actively reflecting on shared knowledge. Despite initiatives to facilitate inclusiveness, research shows that embracing and learning from diverse perspectives is difficult. Using the concept of 'epistemic injustice', pointing at practices of someone's knowledge being unjustly disqualified or devalued, we analyze the way incident investigations are organized and executed with the aim to understand why it is difficult to embrace and learn from the multiple perspectives voiced in incident investigations. We draw from 73 semi-structured interviews with healthcare leaders, managers, healthcare professionals, incident investigators and inspectors, document analyses and ethnographic observations. Our analysis identified several structures in the incident investigation process, that can promote or hinder an actor's epistemic contribution in the process of incident investigations. Rather than repeat calls to 'involve more' and 'listen better', we encourage policy makers to be mindful of and address the structures that can cause epistemic injustice. This can improve the outcome of incident investigations and can help to do justice to the lived experiences of the involved actors in the aftermath of a serious incident.

Impact of an Original Methodological Tool on the Identification of Corrective and Preventive Actions After Root Cause Analysis of Adverse Events in Health Care Facilities: Results of a Randomized Controlled Trial

OBJECTIVE

The aim of the study was to assess the effectiveness of a new methodological tool for the identification of corrective and preventive actions (CAPAs) after root cause analysis of health care-related adverse events.

METHODS

From January to June 2010, we conducted a randomized controlled trial involving risk managers from 111 health care facilities of the Aquitaine Regional Center for Quality and Safety in Health Care (France). Fifty-six risk managers, randomly assigned to two groups (intervention and control), identified CAPAs in response to two sequentially presented adverse event scenarios. For the baseline measure, both groups used their usual adverse event management tools to identify CAPAs in each scenario. For the experimental measure, the control group continued using their usual tools, whereas the intervention group used a new tool involving a systemic approach for CAPA identification. The main outcome measure was the number of CAPAs the participants identified that matched a criterion standard established by eight experts.

RESULTS

Baseline mean number of identified CAPAs did not differ between the two groups (P = 0.83). For the experimental measure, significantly more CAPAs (P = 0.001) were identified by the intervention group (mean [SD] = 4.6 [1.7]) than by the control group (mean [SD] = 2.8 [1.2]).

CONCLUSIONS

For the two scenarios tested, more relevant CAPAs were identified with the new tool than with usual tools. Further research is needed to assess the effectiveness of the new tool for other types of adverse events and its impact on patient safety.

Enhancing Reporting of After Action Reviews of Public Health Emergencies to Strengthen Preparedness: A Literature Review and Methodology Appraisal

OBJECTIVE

This literature review aimed to identify the range of methods used in after action reviews (AARs) of public health emergencies and to develop appraisal tools to compare methodological reporting and validity standards.

METHODS

A review of biomedical and gray literature identified key approaches from AAR methodological research, real-world AARs, and AAR reporting templates. We developed a 50-item tool to systematically document AAR methodological reporting and a linked 11-item summary tool to document validity. Both tools were used sequentially to appraise the literature included in this study.

RESULTS

This review included 24 highly diverse papers, reflecting the lack of a standardized approach. We observed significant divergence between the standards described in AAR and qualitative research literature, and real-world AAR practice. The lack of reporting of basic methods to ensure validity increases doubt about the methodological basis of an individual AAR and the validity of its conclusions.

CONCLUSIONS

The main limitations in current AAR methodology and reporting standards may be addressed through our 11 validity-enhancing recommendations. A minimum reporting standard for AARs could help ensure that findings are valid and clear for others to learn from. A registry of AARs, based on a common reporting structure, may further facilitate shared learning. (Disaster Med Public Health Preparedness. 2019;13:618-625).

Review of serious events in cases of (suspected) child abuse and/or neglect: A RoSE by any other name?

Child abuse and neglect (CAN) cases presenting to health-services may be complex; when things go seriously wrong such as a child death or near miss, cases are reviewed and health-services and professionals subject to intense scrutiny. While there are a variety of mechanisms to review critical incidents in health-services no formal process for the review of cases where child protection is the primary concern exists in Australia. We aimed to develop a systematic process to review serious events in cases of suspected CAN across two health districts in Sydney, so that shared learnings could fuel system change. Drawing upon mapping, case review, literature findings and using quality improvement methodology, we developed a model named Review of Serious Events (RoSE), in suspected cases of CAN. The RoSE model has the key features of: being child focused; seeking to examine care over a period of time; using child protection staff as lead reviewers; involving health professionals/services in the review who have been involved with the child; and actioning systems change at local levels. The RoSE model was trialled through 2014-2015. Eight cases were reviewed using RoSE; cases were similar to those reviewed prior to having a model. Participant feedback from RoSE group processes was overwhelmingly positive; outputs were transparent and accessible to key stakeholders, there was mixed progress with implementation. The RoSE model is a serious case review process that is strongly child-focused, is both investigative and reflective, led by child protection experts; and can be adapted to other settings and systems.

Rebalancing risk management--part 1: The Process for Active Risk Control (PARC)

Risk assessment, by itself, does nothing to reduce risk or improve safety. It can only change outcomes by informing the design and management of effective risk control interventions. But current practice in healthcare risk management suffers from an almost complete lack of support for risk control. This first installment of a 2-part series on rebalancing risk management describes a new framework to guide risk control practice: The Process for Active Risk Control.

The Active Risk Control (ARC) toolkit: a new approach to designing risk control interventions

Current practice in healthcare risk management is supported by many tools for risk assessment (understanding problems), but none for risk control (solving problems).

THE RESULTS

a failure to improve safety, and a waste of the investment made in risk assessment. The Active Risk Control (ARC) Toolkit, available for free, fills this void with a systematic, structured approach to risk control.

Paediatric critical incident analysis: lessons learnt on analysis, recommendations and implementation

The objectives of this study were to identify causal and contributing factors of serious patient safety incidents in a paediatric university hospital, to report on ensuing recommendations and to assess the extent of implementation of the recommendations. The possible causal and contributing factors identified in 17 incidents were classified by a system devised by Vincent et al. Proposed recommendations were classified by the same system, and degrees of implementation were established. A median of 5 causal and contributing factors per incident were identified. Twenty-two percent of all factors were related to teamwork and 22 % to task factors. A median of 5 recommendations per analysis were formulated. Most recommendations were related to task factors (36 %). The time load of each analysis was a mean of 27 h. One third of the recommendations have been acted upon, mostly those related to task and team factors.

CONCLUSION

Incident analysis is time-consuming but yields indispensable information on causal and contributing factors, presenting numerous opportunities for quality improvement. The value of these analyses could be improved by appointing responsibilities and setting up time frames for implementation. A bottom-up approach with managerial support appears to be a key to turning incident analysis and quality improvement into an ongoing process.

Trust-level risk evaluation and risk control guidance in the NHS East of England

In recent years, the healthcare sector has adopted the use of operational risk assessment tools to help understand the systems issues that lead to patient safety incidents. But although these problem-focused tools have improved the ability of healthcare organizations to identify hazards, they have not translated into measurable improvements in patient safety. One possible reason for this is a lack of support for the solution-focused process of risk control. This article describes a content analysis of the risk management strategies, policies, and procedures at all acute (i.e., hospital), mental health, and ambulance trusts (health service organizations) in the East of England area of the British National Health Service. The primary goal was to determine what organizational-level guidance exists to support risk control practice. A secondary goal was to examine the risk evaluation guidance provided by these trusts. With regard to risk control, we found an almost complete lack of useful guidance to promote good practice. With regard to risk evaluation, the trusts relied exclusively on risk matrices. A number of weaknesses were found in the use of this tool, especially related to the guidance for scoring an event's likelihood. We make a number of recommendations to address these concerns. The guidance assessed provides insufficient support for risk control and risk evaluation. This may present a significant barrier to the success of risk management approaches in improving patient safety.

Generating Options for Active Risk Control (GO-ARC): introducing a novel technique

BACKGROUND

After investing significant amounts of time and money in conducting formal risk assessments, such as root cause analysis (RCA) or failure mode and effects analysis (FMEA), healthcare workers are left to their own devices in generating high-quality risk control options. They often experience difficulty in doing so, and tend toward an overreliance on administrative controls (the weakest category in the hierarchy of risk controls). This has important implications for patient safety and the cost effectiveness of risk management operations. This paper describes a before and after pilot study of the Generating Options for Active Risk Control (GO-ARC) technique, a novel tool to improve the quality of the risk control options generation process.

OUTCOME MEASURES

The quantity, quality (using the three-tiered hierarchy of risk controls), variety, and novelty of risk controls generated.

RESULTS

Use of the GO-ARC technique was associated with improvement on all measures.

CONCLUSIONS

While this pilot study has some notable limitations, it appears that the GO-ARC technique improved the risk control options generation process. Further research is needed to confirm this finding. It is also important to note that improved risk control options are a necessary, but not sufficient, step toward the implementation of more robust risk controls.

Clinical errors and medical negligence

This paper discusses the definition, nature and origins of clinical errors including their prevention. The relationship between clinical errors and medical negligence is examined as are the characteristics of litigants and events that are the source of litigation. The pattern of malpractice claims in different specialties and settings is examined. Among hospitalized patients worldwide, 3-16% suffer injury as a result of medical intervention, the most common being the adverse effects of drugs. The frequency of adverse drug effects appears superficially to be higher in intensive care units and emergency departments but once rates have been corrected for volume of patients, comorbidity of conditions and number of drugs prescribed, the difference is not significant. It is concluded that probably no more than 1 in 7 adverse events in medicine result in a malpractice claim and the factors that predict that a patient will resort to litigation include a prior poor relationship with the clinician and the feeling that the patient is not being kept informed. Methods for preventing clinical errors are still in their infancy. The most promising include new technologies such as electronic prescribing systems, diagnostic and clinical decision-making aids and error-resistant systems.

Root cause analyses performed in a children's hospital: events, action plan strength, and implementation rates

This study describes the types of events leading to the performance of root cause analyses (RCA) and the implementation rate and quality of the action plans developed for RCAs performed at a free standing children's hospital. Twenty serious adverse events resulting in RCAs took place between January 2007 and June 2009. A wide variety of events triggered RCAs however, 30% involved medication errors. Seventy-eight action plans were developed with an average of 3.9 ± 1.3 per RCA. Action plans were classified as weaker 46% of the time, intermediate 44% of the time, and stronger 10% of the time. Intermediate or stronger action plans were developed to address 90% of the events. Ninety-five percent of the action plans were implemented. This study demonstrates that RCA can be effectively utilized to consistently generate moderate and high impact action plans to address a diverse array of adverse events within a children's hospital. Near complete implementation of action plans can be achieved.