Complementing Root Cause Analysis With Improvement Strategies to Optimize Venous Thromboembolism Prophylaxis in Patients With Epidural Catheters

Abstract

Background and Objectives: High reliability organizations in health care must identify defects and systematically approach causal factors with subsequent process redesign to achieve goals important to patients, families, and staff. Root cause analysis (RCA) is a commonly leveraged strategy for reviewing adverse events and can yield immense benefits toward patient safety when applied alongside complementary change management strategies such as Lean and Six Sigma. We performed an RCA in response to a hospital-acquired venous thromboembolism (VTE) event in a postoperative patient for which pharmacologic VTE prophylaxis was not appropriately resumed following removal of an epidural catheter. Methods: A multidisciplinary stakeholder team was assembled to further understand the details of the event. A current process map was created and non-value-added steps were identified. Causal analysis revealed that frequent staff turnover, variable methods of communication between stakeholders, inconsistent responsibilities with respect to ordering and administering pharmacologic VTE prophylaxis, and lack of an established standard work process were key contributors toward the defect of concern. Several countermeasures were introduced to combat these identified root causes, including shifting responsibility for managing VTE prophylaxis orders periepidural catheter removal from the surgical house staff to our regional anesthesia service, and creation of an epidural catheter heparin restart order set, which in one step places an order to resume prophylaxis following catheter removal at a specific time. Recommendations from this session were disseminated to staff through previously established huddles that are a component of our daily management system. Results: Postintervention, review of our updated process demonstrated a reduction in variability through establishment of standard work that is primarily owned by a constant factor in this care pathway (our regional anesthesia team). On review of the subsequent 10 cases of patients with epidural catheters, all patients receiving pharmacologic VTE prophylaxis had a maximum of 1 dose stopped for epidural catheter removal, therefore minimizing time without VTE prophylaxis. Conclusions: RCA can be utilized in the aftermath of an adverse event to establish causal factors and identify countermeasures to prevent recurrence of such an event. It can be further augmented with additional change management strategies including Lean, Six Sigma, the Model for Improvement, and failure modes and effects analysis. These strategies allowed us to design effective error-reducing strategies to achieve a more reliable process, which yielded reduced VTE prophylaxis administration defects that in turn has prevented recurrence of hospital-acquired VTE in patients with epidural catheters.

Exploring the “Black Box” of Recommendation Generation in Local Health Care Incident Investigations: A Scoping Review

“…Starting with hierarchies, this review demonstrates not only their widespread use but also variety and variation 5,15,16,26,28,29,35,38,39,64–66 . These hierarchies, largely originating from non–health care settings, 48,67 are used in health care with minimal empirical evidence 38 .…”

“…Starting with hierarchies, this review demonstrates not only their widespread use but also variety and variation. 5,15,16,26,28,29,35,38,39,[64][65][66] These hierarchies, largely originating from non-health care settings, 48,67 are used in health care with minimal empirical Before this review, there have been challenges of the use of hierarchies to predict recommendation effectiveness, 47,48 with arguments that recommendations should be judged on how well they align with the identified risks and context, 46 their likelihood of effecting necessary change, 68 or level of system targeted for change. 47 Our review suggests that hierarchies may not yet be widely used in practice, but with the growing number of variations and lack of consensus, they have the potential to cause confusion for hospital safety teams looking to adopt evidence-based approaches.…”