Root cause analysis applied to the investigation of serious untoward incidents in mental health services

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.

Six Major Steps to Make Investigations of Suicide Valuable for Learning and Prevention

OBJECTIVE

The decline in suicide rates has leveled off in many countries during the last decade, suggesting that new interventions are needed in the work with suicide prevention. Learnings from investigations of suicide should contribute to the development of these new interventions. However, reviews of investigations have indicated that few new lessons have been learned. To be an effective tool, revisions of the current investigation methods are required. This review aimed to describe the problems with the current approaches to investigations of suicide as patient harm and to propose ways to move forward.

METHODS

Narrative literature review.

RESULTS

Several weaknesses in the current approaches to investigations were identified. These include failures in embracing patient and system perspectives, not addressing relevant factors, and insufficient competence of the investigation teams. Investigation methods need to encompass the progress of knowledge about suicidal behavior, suicide prevention, and patient safety.

CONCLUSIONS

There is a need for a paradigm shift in the approaches to investigations of suicide as potential patient harm to enable learning and insights valuable for healthcare improvement. Actions to support this paradigm shift include involvement of patients and families, education for investigators, multidisciplinary analysis teams with competence in and access to relevant parts across organizations, and triage of cases for extensive analyses. A new model for the investigation of suicide that support these actions should facilitate this paradigm shift.HIGHLIGHTSThere are weaknesses in the current approaches to investigations of suicide.A paradigm shift in investigations is needed to contribute to a better understanding of suicide.New knowledge of suicidal behavior, prevention, and patient safety must be applied.

Causation, historiographic approaches and the investigation of serious adverse incidents in mental health settings

To improve the safety of healthcare systems, it is necessary to understand harm-related events that occur in these systems. In mental health services, particular attention is paid to harm arising from the actions of patients against themselves or others. The primary intention of examining these adverse events is to inform changes to care provision so as to reduce the likelihood of the recurrence of such events. The predominant approach to investigating adverse incidents has relied on the cause-and-effect conceptualisation of past events. Whilst the merits of approaches which are reliant on cause-and-effect narratives have been questioned, alternatives models to explain adverse incidents in health settings have not been theoretically or empirically tested. This novel article (i) examines the notion of causation (and the related notion of omission) in the context of explaining adverse events in mental health settings, and (ii) draws on a long-established discipline devoted to the study of how the past is interpreted (namely historiography) to theoretically investigate the innovative application of two historiographical approaches (i.e. counterfactual analysis and historical materialism) to understanding adverse events in mental health settings.

A study of the implementation of patient safety policies in the NHS in England since 2000: what can we learn?

PURPOSE

Despite repeated policy initiatives, progress in improving patient safety in the National Health Service (NHS) in England over the past two decades has been slow. The NHS Patient Safety Strategy (NHS England and NHS Improvement, 2019), which is being implemented currently, aims to address this problem. The purpose of this study is to identify learning from the implementation of past patient safety policies and thereby suggest means of supporting the NHS in delivering the current policy initiative successfully.

DESIGN/METHODOLOGY/APPROACH

The authors identified key health policies in the domain of patient safety, published since 2000, by searching the United Kingdom (UK) government website. Discussion papers from the research literature concerning these policies were collated and reviewed. The authors then used a thematic analysis approach to identify themes discussed within these papers. These themes represent factors that support the effective delivery of patient safety policy initiatives.

FINDINGS

Within the discussion papers the authors collated, concerning 11 patient safety policies implemented between 2000 and 2017, five inter-related core themes of capability, culture, systems, candour and leadership were identified. By evaluating these themes and identifying composite sub-themes, a conceptual framework is presented that can be used to support the delivery of patient safety policy initiatives to maximise their impact.

ORIGINALITY/VALUE

The conceptual framework the authors illustrate, arising from this new contribution to the body of knowledge, can be translated into a novel self-assessment for individual NHS trusts to understand organisational development areas in the domain of patient safety improvement.

Back So Soon? Part 2: Use of the 5 "Whys" Process in Unplanned Hospital Readmissions

PURPOSE/OBJECTIVES

Readmission prevention strategies are the focus of many hospitals, but despite these efforts, unplanned, all-payer hospital readmission rates are increasing. The purpose of this study was to use root cause analysis (RCA) to explore the main cause (medical, behavioral health, and/or social) for the unplanned 30-day readmissions that the Readmission Prevention Team followed up and then to use this data to change and/or refine discharge planning interventions.

PRIMARY PRACTICE SETTING

The primary practice setting was the 229-bed study hospital where subjects with 30-day unplanned readmissions who were followed up by the Readmission Prevention Team were admitted. The venues that subjects were readmitted from were noted as home without services, home with home care, skilled nursing facility (SNF), acute rehab, physician office, hospice/palliative care, and refused care.

METHODOLOGY AND SAMPLE

Using a descriptive, correlational, qualitative design, demographic data (age, gender, days between discharge and readmission, and the venue from which the patient was readmitted) were collected from the RCA worksheets of each subject with an unplanned hospital readmission within 30 days.

RESULTS

Among the 150 subjects, the main cause for readmission was medical (92%), with 19 of the subjects (13%) demonstrating multiple root causes. Women were readmitted more frequently than men, and the prominent age range was the 70s and 80s. The two main readmission venues were home with home care (54.7%) and skilled nursing facilities (23.3%).

IMPLICATIONS FOR CASE MANAGEMENT

Medical was the chief cause of readmissions in this study, with many case management interventions noted in the literature to address these issues. Behavioral health and social issues were responsible for 13% of the readmissions. These issues are more complex, and hospitals should review the interventions that they have in place and develop others that are needed to decrease these types of readmissions.Home with home care was the main venue of readmission, with return from a skilled nursing facility (SNF) being the second. Potential interventions to decrease these unplanned hospital readmissions might include developing a backup discharge plan (Option B) and developing improved communication avenues between the hospital emergency department and the SNF that might lead to the patient returning to the SNF versus being admitted.

Mental Health Inquiries in the Case of Homicide

We aimed to identify features of New Zealand government-commissioned inquiries into the provision of mental health services after homicides committed by service users. The analysis of five reports from 1992 to 2016 identified similarities across reports, which included documenting a process; responding to a set terms of reference; detailing a case chronology, risk assessment, team and system issues; making recommendations and giving opportunities to clinicians to respond to adverse comments. Differences included selecting key informants and acknowledging limitations of scope. The inquiries did not specify a means to disseminate findings to stakeholders and follow up recommendations. Unrealised opportunities include attention to relationships between stakeholders and ways to support learning from inquiries. There is no standardised approach to conducting statutory inquiries into mental health services following a homicide. This limits the value of such inquiries for learning and service improvement. We recommend a standardised framework be developed to guide inquiries.

Learning from critical incidents

Critical incident reviews are an integral part of modern psychiatric practice. The issue is central to the clinical governance agenda in the UK, yet there is widespread debate about their usefulness. There is a lack of systematic research into their impact on clinical outcomes, with most authors commenting on their form, their political implications, and whether they should exist at all. This article explores the historical basis to incident investigation, outlines an ‘ideal’ method of review and discusses the concepts of the learning organisation and root cause analysis. Further discussion focuses on what the objectives of critical incident review might be and whether organisations as a whole can learn from them.

Oxford serious incident review: 7 years on

In 2000, an article published in this journal described a method of reviewing serious incidents based on peer group discussion, a model then in its sixth year (Rose, 2000). This paper describes how the model has changed in response to the National Health Service (NHS) developments since then.

A Model for Incident Review Committees in Behavioral Health Settings

Despite the fact that incident review committees have been a key component of quality improvement in behavioral health settings for decades, specific models of how these committees are structured and operate are not well described. We present a model for an incident review committee that has been implemented in 2 large, academic acute care psychiatric hospitals. We believe the model not only permitted us to efficiently and effectively review untoward incidents, but that it also provided an approach to calibrating standards of care for the institution, engaging physicians in an interdisciplinary effort, promulgating a culture of quality review and improvement throughout the organization, promoting continuity and sustainability of the incident review process, and, most importantly, driving beneficial change in clinical practice. Demonstration of the effectiveness of this model requires formal investigation.

After an inpatient suicide: the aim and outcome of review mechanisms

OBJECTIVE

To describe the intent and process of reviews undertaken following the death by suicide of an inpatient and suggest possible improvements.

METHOD

The current processes of review undertaken in Victoria following the death by suicide of an inpatient were considered in the context of a review of unnatural, unexpected or violent inpatient deaths undertaken by the Chief Psychiatrist of Victoria in late 2011.

RESULTS

Review processes seeking to elucidate a cause or to find errors in the system that may have contributed to an incident are not always suitable nor sufficient in cases of inpatient suicide, where the patient's actions (as opposed to the actions or inactions of clinicians) led to patient death; therefore, the cause of death is not independent of the patient's condition and the treatment provided.

CONCLUSION

While Root Cause Analysis remains a useful methodology, review of inpatient suicides should go beyond examination of systems issues only, and include consideration of the care and treatment provided: whether it met accepted clinical standards and was delivered by staff with adequate skills to consider the inherent risks of mental illness. Review of aggregate data has a useful role in identifying significant common features associated with inpatient deaths.