Experience feedback committees: A way of implementing a root cause analysis practice in hospital medical departments

From Reporting to Improving: How Root Cause Analysis in Teams Shape Patient Safety Culture

Background

Given the increasing focus on patient safety in healthcare systems worldwide, understanding the impact of Continuous Quality Improvement Programs (QIPs) is crucial. QIPs, including Morbidity and Mortality Conferences (MMCs) and Experience Feedback Committees (EFCs), have been identified as effective strategies for enhancing patient safety culture. These programs engage healthcare professionals in the identification and analysis of adverse events to foster a culture of safety (ie the product of individual and group value, attitudes, and perceptions about quality and safety). This study aimed to determine whether patient safety culture differed regarding care provider participation in MMCs and EFCs activities.

Methods

A cross-sectional web-only survey was conducted in 2022 using the Hospital Survey on Patient Safety Culture (HSOPS) among 4780 employees at an 1836-bed, university-affiliated hospital in France. We quantified the mean differences in the 12 HSOPS dimension scores according to MMCs and EFCs participation, using Cohen d effect size. We performed a multivariate analysis of variance to examine differences in dimension scores after adjusting for background characteristics.

Results

Of 4780 eligible employees, 1457 (30.5%) participated in the study. Among the respondents, 571 (39.2%) participated in MMCs or EFCs activities. Participants engaged in MMCs or EFCs reported significantly higher scores in six out of twelve HSOPS dimensions, particularly in "Nonpunitive response to error", "Feedback and communication about error", and "Organizational learning" (Overall effect size = 0.14, 95% confidence interval = 0.11 to 0.17, P<0.001). Notably, involvement in both MMCs and EFCs was associated with higher improvements in patient safety culture compared to non-participation or singular involvement in either program. However, certain dimensions such as "Staffing", "Hospital management support", and "Hospital handoffs and transition" showed no significant association with MMCs or EFCs participation, highlighting broader systemic challenges.

Conclusion

The study confirms the positive association between participation in MMCs or EFCs and an enhanced culture of patient safety, emphasizing the importance of such programs in fostering an environment conducive to learning, communication, and nonpunitive responses to errors. While MMCs or EFCs are effective in promoting certain aspects of patient safety culture, addressing broader systemic challenges remains crucial for comprehensive improvements in patient safety.

Leveraging learning systems to improve quality and patient safety in allergen immunotherapy

Adverse events occur in all fields of medicine, including allergy-immunology, in which allergen immunotherapy medical errors can cause significant harm. Although difficult to experience, such errors constitute opportunities for improvement. Identifying system vulnerabilities can allow resolution of latent errors before they become active problems. We review key aspects and frameworks of the medical error response, acknowledging the fundamental responsibility of clinical teams to learn from harm. Adverse event response comprises 4 major phases: (1) event recognition and reporting, (2) investigation (for which root cause analysis can be helpful), (3) improvement (inclusive of the plan-do-study-act cycle), and (4) communication and resolution. Throughout the process, clinician wellness must be maintained. Adverse event prevention should be prioritized, and a human factors engineering approach can be useful. Quality improvement tools and approaches complement one another and together offer a meaningful avenue for error recovery and prevention.

Demystifying the experience of participating in a root cause analysis: A hermeneutic phenomenological study

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.

Team experiences of the root cause analysis process after a sentinel event: a qualitative case study

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.

Root Cause Analysis (RCA) of Adverse Events in One of the Biggest Western Iranian General Hospitals: Short Communication

Background: In developing and underdeveloped countries, medical error is often either not reported or reported improperly for various reasons. Root cause analysis (RCA) is a systematic method to determine how various factors contribute to the occurrence of medical errors. Objectives: The current study analyzed the root cause of one of western Iran’s biggest general hospitals. Methods: This retrospective RCA was conducted through a qualitative approach in 2019 following the National Patient Safety Agency (NPSA) protocol in seven steps: Initialization of the process, collecting and mapping information, identifying issues related to care delivery problems (CDP) or service delivery problems (SDP), event analysis, identifying the involved factors in the event - root causes, providing solutions, implementing solutions, and submission of reports. Results: According to the results of this study, 61 cases were examined, and committees accepted the errors in 11 cases. Here, 49 CDP and 13 SDP factors were identified. Care delivery problems factors were selected for all events based on the team’s viewpoints. Overall, task-related causes (20 cases), individual causes (17 cases), management-related causes (14 cases), training-related causes (8 cases), and causes related to work environment and conditions (7 cases) were specified. Conclusions: Accepting mistakes is the first step in the hope of improvement. In this hospital, only 11 cases of mistakes had been accepted by the authorities. In most cases, the proposed solutions to this issue included personnel training, monitoring system strengthening, and developing and standardizing processes. Overall, this study and other similar studies showed errors during service delivery and through service providers.

Tools for the investigation of adverse events: scoping review

OBJECTIVE

To map, in the literature, the risk management tools aimed at investigating health adverse events.

METHOD

Scoping review according to the Joanna Brigss Institute, with acronym PCC (Population: hospitalized patients, Concept: tools for the investigation of adverse events, and Context: health institutions) carried out in MEDLINE (OVID), EMBASE, LILACS, Scopus, CINAHL, and gray literature.

RESULTS

The search totaled 825 scientific productions, 31 of which met the objective of the study, which consisted of 27 scientific articles and 4 expert consensus. It was possible to carry out a synthesis of the necessary steps for the investigation of adverse events and use of the tools according to the extent of damage.

CONCLUSION

The practice of investigating adverse events should be guided by a thorough understanding of contributing factors, a fair culture, and the involvement of senior leadership.

The The Difficult Case Consultation: An intervention for interprofessional health communication

An interprofessional group of healthcare practitioners sought a new approach to the early detection, prevention, and resolution of “difficult cases” in the inpatient care context. An action research project addressed this need by developing a narrative re-framing tool that helped reveal entrenched assumptions regarding the root causes of difficult cases in the hospital. The intervention method that emerged from the project — the Difficult Case Consultation (DCC) — is a theoretically-grounded process that helps teams to analyze and address complex communication problems in interprofessional healthcare contexts. Collaborative processes grounded in theory have proven to be the most successful when seeking to optimize healthcare team communication. The article describes the collaborative development of the DCC, presents two cases illustrating the process, and describes systemic factors that exacerbated the emergence of difficult cases in the inpatient context.

Clarifying radiology's role in safety events: a 5-year retrospective common cause analysis of safety events at a pediatric hospital

BACKGROUND

Common cause analysis of hospital safety events that involve radiology can identify opportunities to improve quality of care and patient safety.

OBJECTIVE

To study the most frequent system failures as well as key activities and processes identified in safety events in an academic children's hospital that underwent root cause analysis and in which radiology was determined to play a contributing role.

MATERIALS AND METHODS

All safety events involving diagnostic or interventional radiology from April 2013 to November 2018, for which the hospital patient safety department conducted root cause analysis, were retrospectively analyzed. Pareto charts were constructed to identify the most frequent modalities, system failure modes, key processes and key activities.

RESULTS

In 19 safety events, 64 sequential interactions were attributed to the radiology department by the patient safety department. Five of these safety events were secondary to diagnostic errors. Interventional radiology, radiography and diagnostic fluoroscopy accounted for 89.5% of the modalities in these safety events. Culture and process accounted for 55% of the system failure modes. The three most common key processes involved in these sequential interactions were diagnostic (39.1%) and procedural services (25%), followed by coordinating care and services (18.8%). The two most common key activities were interpreting/analyzing (21.9%) and coordinating activities (15.6%).

CONCLUSION

Proposing and implementing solutions based on the analysis of a single safety event may not be a robust strategy for process improvement. Common cause analyses of safety events allow for a more robust understanding of system failures and have the potential to generate more specific process improvement strategies to prevent the reoccurrence of similar errors. Our analysis demonstrated that the most common system failure modes in safety events attributed to radiology were culture and process. However, the generalizability of these findings is limited given our small sample size. Aligning with other children's hospitals to use standard safety event terminology and shared databases will likely lead to greater clarity on radiology's direct and indirect contributions to patient harm.

Root Cause Analysis for Hospital-Acquired Pressure Injury

Root cause analysis (RCA) is a systematic process for identifying the causes of an adverse occurrence or combined with an approach for a response designed to prevent recurrences. This method may be used for continuous quality improvement in a facility or health system. Root cause analysis can aid nurses and hospital risk managers to determine how the system can improve to reduce the number and severity of pressure injuries. The process of RCA begins with being certain the wound is a pressure injury using differential diagnoses of similar appearing skin disease and injury, followed by an examination of the processes of care (human roots) for missed actions or inactions that are linked to development of a particular pressure injury. The final step of RCA is a critical examination of the system (including people and processes) to look for modifiable trends or patterns are identified that are used to prevent recurrences.

How Much of Root Cause Analysis Translates into Improved Patient Safety: A Systematic Review

OBJECTIVES

The aim of this systematic review was to consolidate studies to determine whether root cause analysis (RCA) is an adequate method to decrease recurrence of avoidable adverse events (AAEs).

METHODS

A systematic search of databases from creation until December 2018 was performed using PubMed, Scopus and EMBASE. We included articles published in scientific journals describing the practical usefulness in and impact of RCA on the reduction of AAEs and whether professionals consider it feasible. The Mixed Methods Appraisal Tool was used to assess the quality of studies.

RESULTS

Twenty-one articles met the inclusion criteria. Samples included in these studies ranged from 20 to 1,707 analyses of RCAs, AAEs, recommendations, audits or interviews with professionals. The most common setting was hospitals (86%; n = 18), and the type of incident most analysed was AAEs, in 71% (n = 15) of the cases; 47% (n = 10) of the studies stated that the main weakness of RCA is its recommendations. The most common causes involved in the occurrence of AEs were communication problems among professionals, human error and faults in the organisation of the health care process. Despite the widespread implementation of RCA in the past decades, only 2 studies could to some extent establish an improvement in patient safety due to RCAs.

CONCLUSIONS

RCA is a useful tool for the identification of the remote and immediate causes of safety incidents, but not for implementing effective measures to prevent their recurrence.

Multidisciplinary Simulation Activity Effectively Prepares Residents for Participation in Patient Safety Activities

PURPOSE

In 2017, The Accreditation Council for Graduate Medical Education (ACGME) issued Common Program Requirements that stipulated residents must participate in real or simulated interprofessional patient safety activities, such as root cause analyses (RCA). The requirements also stated that residents should have the opportunity to participate in the disclosure of patient safety events. Our institution supports a large graduate medical education (GME) cohort with approximately 1400 GME learners in more than 100 ACGME programs. Knowing that our university hospital system conducts approximately 15 RCA's per year, our GME leadership charged the Dean of Simulation with developing a pilot simulation activity that would satisfy these educational needs.

METHODS

Four departments (Anesthesia, Emergency Medicine, OB/GYN, and Surgery) assigned a total of 39 learners to participate in the pilot simulation. Learners were divided into groups of 5 to 8 participants representing at least 3 departments. Before the simulation, learners were asked to complete a preactivity questionnaire rating their comfort with the learning objectives and a 10-question multiple choice quiz assessing knowledge of RCA principles. The simulation was 1-hour long and consisted of 2 parts. First, learners participated in a high-fidelity, mannequin-based resuscitation scenario that was scripted to include systems barriers to effective resuscitation. Second, our University Hospital's Vice President of Quality and Safety led participants in a simulated RCA analyzing the systems issues encountered. Finally, all learners completed a postactivity questionnaire and quiz. Preactivity and postactivity data were compared with repeated measures t-tests with p < 0.05 considered significant.

RESULTS

Complete data were available for 38 learners. We observed significant improvements in quiz performance and learners' self-reported abilities to perform tasks related to patient safety and RCA. The simulation activity did not affect learners' anxiety regarding potential participation in an RCA.

CONCLUSIONS

Our data indicate that a 1-hour, introductory-level simulation improved residents' confidence and knowledge related patient safety activities. This training format is efficient, effective, and consistent with the expectations of the new ACGME Common Program Requirement.

The National MDS Natural History Study: design of an integrated data and sample biorepository to promote research studies in myelodysplastic syndromes

Myelodysplastic syndromes (MDS), a spectrum of heterogeneous hematopoietic stem cell diseases, vary in clinical severity, response to therapy, and propensity toward progression to acute myeloid leukemia. These are acquired clonal disorders resulting from somatic mutations within the hematopoietic stem or progenitor cell population. Understanding the natural history and the risk of developing leukemia and other adverse outcomes is dependent on access to well-annotated biospecimens linked to robust clinical and molecular data. To facilitate the acquisition and distribution of MDS biospecimens to the wider scientific community and support scientific discovery in this disease, the National MDS Natural History study was initiated by the National Heart, Lung, and Blood Institute (NHLBI) and is being conducted in collaboration with community hospitals and academic medical centers supported by the National Cancer Institute (NCI). The study will recruit up to 2000 MDS patients or overlapping myeloproliferative neoplasms (MDS/MPN) and up to 500 cases of idiopathic cytopenia of undetermined significance (ICUS). The National MDS Natural History Study (NCT02775383) will offer the world's largest disease-focused tissue biobank linked to longitudinal clinical and molecular data in MDS. Here, we report on the study design features and describe the vanguard phase of 200 cases. The study assembles a comprehensive clinical database, quality of life results, laboratory data, histopathology slides and images, genetic information, hematopoietic and germline tissues representing high-quality biospecimens and data from diverse centers across the United States. These resources will be available to the scientific community for investigator-initiated research.