Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme

Abstract

Background: Research on root cause analysis (RCA), a pivotal component of many patient safety improvement programmes, is limited. Objective: To study a cohort of health professionals who conducted RCAs after completing the NSW Safety Improvement Program (SIP). Hypothesis: Participants in RCAs would: (1) differ in demographic profile from non-participants, (2) encounter problems conducting RCAs as a result of insufficient system support, (3) encounter more problems if they had conducted fewer RCAs and (4) have positive attitudes regarding RCA and safety. Design, setting and participants: Anonymous questionnaire survey of 252 health professionals, drawn from a larger sample, who attended 2-day SIP courses across New South Wales, Australia. Outcome measures: Demographic variables, experiences conducting RCAs, attitudes and safety skills acquired. Results: No demographic variables differentiated RCA participants from non-participants. The difficulties experienced while conducting RCAs were lack of time (75.0%), resources (45.0%) and feedback (38.3%), and difficulties with colleagues (44.5%), RCA teams (34.2%), other professions (26.9%) and management (16.7%). Respondents reported benefits from RCAs, including improved patient safety (87.9%) and communication about patient care (79.8%). SIP courses had given participants skills to conduct RCAs (92.8%) and improve their safety practices (79.6%). Benefits from the SIP were thought to justify the investment by New South Wales Health (74.6%) and committing staff resources (72.6%). Most (84.8%) of the participants wanted additional RCA training. Conclusions: RCA participants reported improved skills and commitment to safety, but greater support from the workplace and health system are necessary to maintain momentum.

Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the gap

“…Our study adds to a growing body of research on the challenges of using RCA (Braithwaite et al, 2006;Wu et al, 2008;Tamuz et al, 2011). We find that in practice difficulties arise at several stages of the RCA process.…”

“…For instance, Braithwaite et al (2006) report that their Australian informants often viewed RCA processes as limited by time constraints, lack of expertise, and difficulties of working with colleagues. Wu et al (2008), examining the use of RCA in North America, show that there are inherent difficulties in translating RCA recommendations into tangible service change.…”

“…While RCA is formally endorsed by policy makers in USA, UK, Australia, and Denmark (Øvretveit, 2005) and is in the process of being adopted by other countries, we have only a partial understanding of the challenges of using this approach, despite research suggesting it is not without problems (Wallace, 2006;Braithwaite et al, 2006;Iedema et al 2006a;2006b, Wu et al, 2008. Building on an extensive 12-months ethnographic study within two large acute hospitals in the UK National Health Service (NHS), we examine how the investigation of clinical incidents is conducted in practice.…”

Improving patient safety culture in general practice: an interview study

“…These discussions contribute to openness and trust. 44,45 Indeed, in this study, participants indicated that discussions around reports helped them remain aware of incidents and to address each other regarding safety issues during daily practice. In this way, safety management was embedded in everyday work.…”

Effectiveness and Efficiency of Root Cause Analysis in Medicine

“…10 In a survey of professionals conducting RCAs, 69.2% felt their recommendations were at least partly implemented. 12 Not all actions aimed to mitigate risk are equal. Some actions, like redesigning a product or process, are strong and have a high probability of reducing harm.…”