Does Root Cause Analysis Improve Patient Safety? A Systematic Review at the Department of Veterans Affairs

Abstract

Background and Objectives: While root cause analysis (RCA) is used to analyze medical errors with a systems approach, evidence demonstrating its effectiveness in reducing patient harm remains sparse. The heterogeneity of the RCA methodology at different health care organizations has posed challenges to studying its value. The Department of Veterans Affairs (VA) has an established and standardized RCA approach, making it an ideal context to study RCA's impact. This review assessed whether implemented interventions recommended by RCAs were effective in mitigating preventable adverse events at the VA. Methods: PubMed, Web of Science, CINAHL and Business Source were searched for studies on RCAs performed at the VA that evaluated effectiveness of interventions and were published between 2010 and 2020. The Appraisal Tool for Cross-sectional Studies (AXIS) was used to assess bias of bias. Results: The majority of studies eliminated during our eligibility process reported on RCAs without attention to their specific impact on patient safety. Ten retrospective studies met inclusion criteria and were part of the final review. Studies were grouped into adverse events related to incorrect surgical/invasive procedures, suicides, falls with injury, and all-cause adverse events. Six studies reported on effectiveness by demonstrating quantitative changes in adverse events over time or by location following a specific intervention. Four studies reported on the effectiveness of implemented interventions using a facility-based rating of “much better” or “better.” Conclusions: Of the studies included in this review, all reported improvements following interventions implemented after RCAs, but with variability in study definitions and methodology to assess effectiveness. Increased reporting of outcomes following RCAs, with an emphasis on quantitative patient-related outcome measures, is needed to demonstrate the impact and value of the RCA.

Pediatric Ventilator-Associated Events Before and After a Multicenter Quality Improvement Initiative

“…Given that performing ACAs could help clinicians identify potential causes or risk factors of PedVAEs, reporting and discussing these ACAs could lead to greater attention to the event and its prevention. Increased reporting in root cause analyses and ACAs have been associated with improved patient outcomes . In the present study, however, both reliable and nonreliable reporters of ACA data showed a centerline shift in PedVAE rates.…”

“…Increased reporting in root cause analyses and ACAs have been associated with improved patient outcomes. [30][31][32] In the present study, however, both reliable and nonreliable reporters of ACA data showed a centerline shift in PedVAE rates. This shift may be associated with the PedVAE education that was provided to both the reliable and nonreliable reporters of ACA data.…”

Validity of root cause analysis in investigating adverse events in psychiatry

“…A review of the existing literature has identified no papers directly addressing the validity of RCA in adverse-event investigation in health or in psychiatry. Most authors have focused on the lack of evaluation of effectiveness of RCA in health, especially with reference to recommendations and action plans, 12,[17][18][19][20][21][22] which are the output of RCAs. Several authors have considered whether RCA is the best method to investigate adverse events in health.…”

Data Show Fleeting Success: Improvement Teams Should Address Root Causes

“…In “Does Root Cause Analysis Improve Patient Safety? A Systematic Review at the Department of Veterans Affairs,” Shah and colleagues1 examine if root cause analysis in the Veterans Health Administration has been effective. The article shows that some investigators collect data on the impact of the improvement, which is encouraging and reassuring.…”