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Abreu T, Freysteinson WM, Clutter P, Aulbach R. Demystifying the experience of participating in a root cause analysis: A hermeneutic phenomenological study. Appl Nurs Res 2023; 74:151746. [PMID: 38007246 DOI: 10.1016/j.apnr.2023.151746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 08/04/2023] [Accepted: 10/24/2023] [Indexed: 11/27/2023]
Abstract
AIM This study aimed to explore registered nurses' experience participating in a root cause analysis (RCA) meeting because of their involvement in an adverse event. BACKGROUND An RCA is the most common strategy used by organizations for adverse event investigations. Nursing healthcare professionals directly involved in an adverse event may be asked to participate in the RCA. However, no studies were found in the literature on their experience. METHODS Semi-structured audio-taped interviews were held with 13 registered nurses who participated in an RCA. Ricoeur's hermeneutic phenomenology guided data analysis. RESULTS Two structural elements represented the world of the nurses: 1) Learning about an RCA, and 2) being on the other side of the RCA table. Three phenomenological themes emerged: 1) anticipatory and embodied fear, 2) to speak or not to speak, 3) the aftermath. CONCLUSION Nurses desire RCA education to assist in understanding and support from nurse leaders throughout the process. Healthcare organizations must create a safe and collaborative environment to empower nurses to speak up and have their voices heard during the RCA process. IMPLICATIONS FOR NURSING LEADERS Nurses want to participate in RCA meetings. However, leaders must demystify the RCA process for nurses through education and training.
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Affiliation(s)
- Tamu Abreu
- Nelda C. Stark College of Nursing, Texas Woman's University, USA.
| | | | - Paula Clutter
- Nelda C. Stark College of Nursing, Texas Woman's University, USA
| | - Rebecca Aulbach
- Nelda C. Stark College of Nursing, Texas Woman's University, USA
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Lea W, Lawton R, Vincent C, O’Hara J. Exploring the "Black Box" of Recommendation Generation in Local Health Care Incident Investigations: A Scoping Review. J Patient Saf 2023; 19:553-563. [PMID: 37712844 PMCID: PMC10662609 DOI: 10.1097/pts.0000000000001164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
BACKGROUND Incident investigation remains a cornerstone of patient safety management and improvement, with recommendations meant to drive action and improvement. There is little empirical evidence about how-in real-world hospital settings-recommendations are generated or judged for effectiveness. OBJECTIVES Our research questions, concerning internal hospital investigations, were as follows: (1) What approaches to incident investigation are used before the generation of recommendations? (2) What are the processes for generating recommendations after a patient safety incident investigation? (3) What are the number and types of recommendations proposed? (4) What criteria are used, by hospitals or study authors, to assess the quality or strength of recommendations made? METHODS Following PRISMA-ScR guidelines, we conducted a scoping review. Studies were included if they reported data from investigations undertaken and recommendations generated within hospitals. Review questions were answered with content analysis, and extracted recommendations were categorized and counted. RESULTS Eleven studies met the inclusion criteria. Root cause analysis was the dominant investigation approach, but methods for recommendation generation were unclear. A total of 4579 recommendations were extracted, largely focusing on individuals' behavior rather than addressing deficiencies in systems (<7% classified as strong). Included studies reported recommendation effectiveness as judged against predefined "action" hierarchies or by incident recurrence, which was not comprehensively reported. CONCLUSIONS Despite the ubiquity of incident investigation, there is a surprising lack of evidence concerning how recommendation generation is or should be undertaken. Little evidence is presented to show that investigations or recommendations result in improved care quality or safety. We contend that, although incident investigations remain foundational to patient safety, more enquiry is needed about how this important work is actually achieved and whether it can contribute to improving quality of care.
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Affiliation(s)
- William Lea
- From the York & Scarborough Teaching Hospital NHS Foundation Trust, University of Leeds, Leeds
- Learning & Research Centre, York Hospital, York
| | - Rebecca Lawton
- Psychology of Healthcare, and NIHR Yorkshire and Humber Patient Safety Translational Research Centre, University of Leeds, Leeds
| | | | - Jane O’Hara
- Healthcare Quality and Safety
- Yorkshire Quality & Safety Research Group, School of Healthcare, Baines Wing, University of Leeds, Leeds, United Kingdom
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Liepelt S, Sundal H, Kirchhoff R. Team experiences of the root cause analysis process after a sentinel event: a qualitative case study. BMC Health Serv Res 2023; 23:1224. [PMID: 37940969 PMCID: PMC10634119 DOI: 10.1186/s12913-023-10178-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/18/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Root cause analysis (RCA) is a systematic approach, typically involving several stages, used in healthcare to identify the underlying causes of a medical error or sentinel event. This study focuses on how members of a Norwegian RCA team experience aspects of an RCA process and whether it complies with the Norwegian RCA method. METHOD Based on a sentinel event in which a child died unexpectedly during childbirth in a Norwegian hospital in 2021, the following research questions are addressed: 1. What was the RCA team's experience of the RCA process? 2. Was there compliance with the Norwegian RCA method in this case? A case study was chosen out of the desire to understand complex social phenomena and to allow in-depth focus on a case. RESULTS The result covered three main themes. The first theme related to the hospital's management system and aspects of the case that made it challenging to follow all recommendations in the Norwegian RCA guidelines. The second theme encompassed external and internal assessment. The RCA team was composed of members with methodological and medical expertise. However, the police's involvement in the case made it complex for the team to carry out the process. The third and final theme covered intrapersonal challenges RCA team members faced. Team members experienced various challenges during the RCA process, including being neutral, dealing with role-related challenges, grappling with ambivalence, and managing the additional time burden and resource constraints. As anticipated in the RCA guidelines, the team's ability to remain neutral was tested. CONCLUSION The findings of this study can help stakeholders better comprehend how an inter-professional RCA teamwork intervention can affect a healthcare organization and enhance the teamwork experience of healthcare staff while facilitating improvements in work processes and patient safety. Additionally, these results can guide stakeholders in creating, executing, utilizing, and educating others about RCA processes.
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Affiliation(s)
- Silje Liepelt
- Department of Health Sciences, Ålesund, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Larsgårdsvegen 2, Ålesund, 6025, Norway.
| | - Hildegunn Sundal
- Faculty of Health Sciences and Social Care, Molde University College, PO. Box 2110, Molde, 6402, Norway
| | - Ralf Kirchhoff
- Department of Health Sciences, Ålesund, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Larsgårdsvegen 2, Ålesund, 6025, Norway
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Kwok YT, Mah AP. Qualitative study on experience of healthcare staff who have undergone a hybrid root cause analysis training programme. BMJ Open Qual 2023; 12:bmjoq-2022-002153. [PMID: 37003599 PMCID: PMC10083879 DOI: 10.1136/bmjoq-2022-002153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 02/05/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Root cause analysis (RCA) is a structured investigation methodology aimed at identifying systems factors to prevent recurrence of incidents. To enhance staff's knowledge and skills, a hybrid RCA training course was conducted in February 2021. Overseas instructors conducted training online and local participants attended the training together physically with onsite facilitator support. This study aimed at understanding the experiences of trainees who have undergone the training, evaluated its effectiveness and identified opportunities to enhance RCA training quality in the future. METHODS A qualitative study using virtual synchronous focus group interviews was conducted. Purposive sampling was adopted to invite all trainees from the RCA training course to join. A semistructured interview was used to guide the study participants to share their experiences. All groups were audio-recorded, transcribed verbatim and anonymised for data analysis. RESULTS Overall, 6 focus groups with 19 participants were held between July and November 2021. Five key themes were identified including: (1) training contents, (2) perceptions of RCA, (3) challenges in RCA, (4) hybrid training and (5) future perspectives. Participants felt the RCA training was useful and broadened their understanding in incident investigation. More in-depth training in interviewing skills, report writing with practical sessions could further enhance their competencies in RCA. Participants accepted the use of hybrid online-offline training well. Most participants would welcome an independent organisation to conduct RCA as findings would be more objective and recommendations more effective. CONCLUSIONS This study provided an evaluation on the effectiveness of a hybrid RCA training course. Healthcare and training organisations can consider this training mode as it could reduce the cost of training and enhance flexibility in course arrangement while preserving quality and effectiveness. Virtual focus groups to interview participants were found to be convenient as it minimised travelling time and onsite arrangement while maintaining the quality of discussion.
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Affiliation(s)
- Yick-Ting Kwok
- Root Cause Analysis Review Workgroup, Hospital Authority, Hong Kong, Hong Kong
- Quality and Safety Division, New Territories West Cluster, Hospital Authority, Hong Kong, Hong Kong
| | - Alastair P Mah
- Root Cause Analysis Review Workgroup, Hospital Authority, Hong Kong, Hong Kong
- Medical Affairs, United Family Healthcare, Beijing, China
- Faculty of Health, School of Medicine, Deakin University, Geelong, Victoria, Australia
- Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
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Müller BS, Lüttel D, Schütze D, Blazejewski T, Pommée M, Müller H, Rubin K, Thomeczek C, Schadewitz R, Kintrup A, Heuzeroth R, Beyer M, Schwappach D, Hecker R, Gerlach FM. Strength of Safety Measures Introduced by Medical Practices to Prevent a Recurrence of Patient Safety Incidents: An Observational Study. J Patient Saf 2022; 18:444-448. [PMID: 35948293 DOI: 10.1097/pts.0000000000000953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to analyze the strength of safety measures described in incident reports in outpatient care. METHODS An incident reporting project in German outpatient care included 184 medical practices with differing fields of specialization. The practices were invited to submit anonymous incident reports to the project team 3 times for 17 months. Using a 14-item coding scheme based on international recommendations, we deductively coded the incident reports and safety measures. Safety measures were classified as "strong" (likely to be effective and sustainable), "intermediate" (possibly effective and sustainable), or "weak" (less likely to be effective and sustainable). RESULTS The practices submitted 245 incident reports. In 160 of them, 243 preventive measures were described, or an average of 1.5 per report. The number of documented measures varied from 1 in 67% to 4 in 5% of them. Four preventive measures (2%) were classified as strong, 37 (15%) as intermediate, and 202 (83%) as weak. The most frequently mentioned measures were "new procedure/policy" (n = 121) and "information/notification/warning" (n = 45). CONCLUSIONS The study provides examples of critical incidents in medical practices and for the first time examines the strength of ensuing measures introduced in outpatient care. Overall, the proportion of weak measures is (too) high, indicating that practices need more support in identifying strong measures.
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Affiliation(s)
- Beate S Müller
- From the Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Dagmar Lüttel
- Aktionsbündnis Patientensicherheit e.V., Berlin, Germany
| | - Dania Schütze
- From the Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Tatjana Blazejewski
- From the Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Marina Pommée
- From the Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | | | | | | | - Romy Schadewitz
- Ärztliches Zentrum für Qualität in der Medizin, Berlin, Germany
| | - Andreas Kintrup
- Kassenärztliche Vereinigung Westfalen-Lippe, Dortmund, Germany
| | | | - Martin Beyer
- From the Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | | | - Ruth Hecker
- Aktionsbündnis Patientensicherheit e.V., Berlin, Germany
| | - Ferdinand M Gerlach
- From the Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
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Lima LAD, Silva LCDMA, Dantas JKDS, Lima MSMD, Dantas DV, Dantas RAN. Root Cause Analysis, Failures and Effects in pediatric total quality management: a scoping review. Rev Bras Enferm 2021; 74:e20200954. [PMID: 34431936 DOI: 10.1590/0034-7167-2020-0954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 03/23/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES to analyze the applicability of Root Cause Analysis and Failure Mode and Effect Analysis tools, aiming to improve care in pediatric units. METHODS this is a scoping review carried out according to the Joanna Briggs Institute guidelines, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes extension for Scoping Reviews. Search took place in May 2018 on 15 data sources. RESULTS search totaled 8,254 studies. After using the relevant inclusion and exclusion criteria, 15 articles were included in the review. Of these, nine were published between 2013 and 2018, 12 used Failure Mode and Effect Analysis and 11 carried out interventions to improve the quality of the processes addressed, showing good post-intervention results. FINAL CONSIDERATIONS the application of the tools indicated significant changes and improvements in the services that implemented them, proving to be satisfactory for detecting opportunities for improvement, employing specific methodologies for harm reduction in pediatrics.
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Hibbert PD, Clay-Williams R, Westbrook J, Reed RL, Georgiou A, Wiles LK, Molloy CJ, Braithwaite J. Reducing preventable harm to residents in aged care: A systems approach. Australas J Ageing 2020; 40:72-76. [PMID: 33006429 DOI: 10.1111/ajag.12861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/30/2020] [Accepted: 09/02/2020] [Indexed: 11/30/2022]
Abstract
Residents in Australian aged care facilities can suffer serious preventable harm from incidents ('adverse events' (AEs)). An inadequate response to AEs by aged care facilities can compound distress to residents and their families/carers. Facilities have an obligation to respond to and investigate AEs involving residents, learn from them, and take action to reduce the chance of them reoccurring . Residential aged care facilities have a duty to create a culture where staff, residents and families/carers feel comfortable reporting AEs or complaints; there is adequate time and resources to manage AEs and complaints; and feedback is provided to staff, residents and their families/carers on the results of investigations into AEs/complaints. The Aged Care Quality and Safety Commission's role should encompass additional governance functions such as sharing results and lessons learnt from AEs, complaints and investigations across Australia, assuring the quality of investigations conducted by facilities, and undertaking national system-wide investigations.
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Affiliation(s)
- Peter D Hibbert
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia.,Australian Centre for Precision Health, Cancer Research Institute, School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia.,South Australian Health & Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia
| | - Robyn Clay-Williams
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Johanna Westbrook
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Richard L Reed
- Flinders University General Practice and Primary Health Care, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Andrew Georgiou
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Louise K Wiles
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia.,Australian Centre for Precision Health, Cancer Research Institute, School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia.,South Australian Health & Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia
| | - Charlotte J Molloy
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia.,Australian Centre for Precision Health, Cancer Research Institute, School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia.,South Australian Health & Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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