A12 (18): Adverse Events
Article
Root Cause Analysis: Learning from Adverse Safety Events
Speciality
Practice Management
Approved for THREE (3) Clinical Continuing Educational Units (CEU’s)
Root Cause Analysis: Learning from Adverse Safety Events
Practice Management
Approved for THREE (3) Clinical Continuing Educational Units (CEU’s)
An adverse event is one that results in unintended harm to the patient by an act of commission or omission, rather than by the underlying disease or condition of the patient.
Despite the best efforts of individuals and organizations to prevent harm in medicine, serious adverse events still take place.
Examples of adverse events include a patient slipping / falling while walking from the reception area to a consultation / procedure room, a missed imaging finding or an essential element of patient history (such as an allergy) being missed leading to inappropriate treatment.
When these occur, the first priority of health care providers is to ensure that the patient’s condition is managed appropriately. Despite the initial response, it is essential that health care professionals, both individually and as part of a team / organisation, learn from such events and make appropriate changes to decrease the likelihood that such events will recur.
Root cause analysis is a widely accepted structured process for accomplishing this goal.
Serious adverse events continue to occur in clinical practice, despite our best preventive efforts. It is essential to learn from such events and to decrease the likelihood that such events will recur. Root cause analysis (RCA) is a widely accepted structured process for accomplishing this goal.
Is a process to identify factors that underlie variation in performance or that predispose an event toward undesired outcomes and allow for development of effective strategies to decrease the likelihood of similar adverse events occurring in the future.
An RCA process should be performed within the environment of a culture of safety, focusing on underlying system contributors and, in a confidential manner.
An RCA consists of three fundamental components:
(These definitions are key to some of the questions)
Adverse event: Event is one that results in unintended harm to the patient by an act of commission or omission, rather than by the underlying disease or condition of the patient. The term adverse does not imply whether the event may have been preventable.
Serious event: Event is one that results in death, loss of a body part, disability, or loss of bodily function that lasts more than 7 days or is still present at the time of discharge from an inpatient health care facility.
Sentinel event: Event is an unexpected occurrence that involves death, serious physical or psychological injury, or the risk thereof, meaning any process variation for which a recurrence would carry a substantial chance of a serious adverse outcome.
Active error: Active error is one that occurs at the level of the frontline operator, the effect of which is felt immediately or almost immediately.
(These definitions are key to some of the questions)
Near miss: Event or situation that did not produce patient harm, but only because of intervening factors, such as patient health or timely intervention.
Mitigation: An action or circumstance that prevents or moderates the progression of an incident that would result in severe harm to a patient. The focus is less on preventing errors, per se, and more on preventing harm from errors. Examples include implementation of a patient transfer mechanism, establishment of an educational program for venous access evaluation, and enforcement of structured reporting use.
Patient safety practice: Patient safety practice refers to discrete and clearly recognizable evidence-based processes or manners of providing care that reduce the likelihood of harm due to the systems, processes, or environments of care . An example is the introduction of checklists, which have been shown to reduce perioperative morbidity and mortality.
Suggested sequential steps in managing an adverse event are discussed below.
However, if an injury has occurred to a patient, all immediate attention must be focused on managing the patient’s condition and limiting the extent of injury.
The first step is to recognize or anticipate a potential problem and to have systems and processes in place for detecting such problems before or as soon as they occur.
Effective communication processes should be in place to make the appropriate people aware that something bad has happened, which then triggers an appropriate and timely response.
Organize a multidisciplinary team
This may take place several days after the initial event, depending on the circumstances and their effect on personnel.
Team members should include:
Delve more deeply into factors that support the processes.
It is often helpful to create a flowchart of the sequence and timeline of events that includes the actual sequence, what the ideal sequence would have been, and the policies and protocols related to each step in the process
Affinity Diagram — assesses the potential causes of the event.
Error Taxonomy — Classification of contributors to an adverse event
Use of Appropriate RCA Tools: Once the event has been defined clearly, a structured RCA is performed to consider both human (active) and system or process (latent) contributing factors.
“five whys” approach
Cause-and-effect (Ishikawa diagram)
Causal tree mapping
Feed change ideas into quality improvement process
Monitor changed process
In conclusion, when an adverse event occurs, it is essential to perform an RCA to identify all possible contributors. Tools that can be used to perform the analysis include a timeline, the “five whys” approach for determining causation, cause-and-effect diagrams, causal tree mapping, affinity diagrams, and Pareto charts. On the basis of this analysis, strategies should be implemented to mitigate the future occurrence of similar adverse events.