Review of alternatives to root cause analysis: developing a robust system for incident report analysis

Hagley, Gregory; Mills, Peter D.; Watts, Bradley V.; Wu, Albert W.

doi:10.1136/bmjoq-2019-000646

Cited by 25 publications

(26 citation statements)

References 89 publications

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“…Effective multidisciplinary staff participation was favored by capitalizing on a pre-existing MMR process including a structured reporting tool. As it was already suggested, the MMR, which is a regulatory obligation in many countries, may represent an alternative to overcome the limited methods and intensity of resources (time, human and financial) to conduct a formal RCA [33,34,35]. The use of a common taxonomy (ALARM framework) for the contributory factors, the recovery factors, and the corrective measures supported a comprehensive approach to patterns identification and improvement strategies recommendations.…”

Section: Discussionmentioning

confidence: 92%

Contributing factors to severe complications after liver resection: an aggregate root cause analysis in 105 consecutive patients

et al. 2020

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Background The aggregate root cause analysis (AggRCA) was designed to improve the understanding of system vulnerabilities contributing to patient harm, including surgical complications. It remains poorly used due to methodological complexity and resource limitations. This study aimed to identify the main patterns contributing to severe complications after liver resection using an AggRCA. Methods This was a retrospective qualitative study aimed to identify the main patterns contributing to severe complications, defined as strictly higher than grade IIIa according to the Clavien-Dindo classification within the first 90 days after liver resection. All consecutive severe complications that occurred between January 1st, 2018 and December 31st, 2019 were identified from an electronic database and included in an AggRCA. This included a structured morbidity and mortality review (MMR) reporting tool based on 50 contributory factors adapted from 6 ALARM categories: “Patient”, “Tasks”, “Individual staff”, “Team”, “Work environment”, and “Management and Institutional context”. Data resulting from individual-participant root cause analysis (RCA) of single-cases were validated collectively then aggregated. The main patterns were suggested from the contributory factors reported in more than half of the cases. Results In 105 consecutive liver resection cases, 15 patients (14.3%) developed severe postoperative complications, including 5 (4.8%) who died. AggRCA resulted in the identification of 36 contributory factors. Eight contributory factors were reported in more than half of the cases and were compiled in three entangled patterns: (1) Disrupted perioperative process, (2) Unplanned intraoperative change, (3) Ineffective communication. Conclusion A pragmatic aggregated RCA process improved our understanding of system vulnerabilities based on the analysis of a limited number of events and a reasonable resource intensity. The identification of patterns contributing to severe complications lay the rationale of future contextualized safety interventions beyond the scope of liver resections.

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Section: Discussionmentioning

confidence: 92%

Contributing factors to severe complications after liver resection: an aggregate root cause analysis in 105 consecutive patients

et al. 2020

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“…Effective multidisciplinary staff participation was favored by capitalizing on a pre-existing MMR process including a structured reporting tool. As it was already suggested, the MMR, which is a regulatory obligation in many countries, may represent an alternative to overcome the limited methods and intensity of resources (time, human and nancial) to conduct a formal RCA [35,36]; [37]. The use of a common taxonomy (ALARM framework) for the contributory factors, the recovery factors, and the corrective measures supported a comprehensive approach to patterns identi cation and improvement strategies recommendations.…”

Section: Patterns Contributing To Severe Complicationsmentioning

confidence: 92%

Contributing factors to severe complications after liver resection: an aggregate root cause analysis in 105 consecutive patients.

Houssaini

Lahnaoui

Souadka

et al. 2020

Preprint

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Background: The aggregate root cause analysis (AggRCA) was designed to improve the understanding of system vulnerabilities contributing to patient harm, including surgical complications. It remains poorly used due to methodological complexity and resource limitations. This study aimed to identify the main patterns contributing to severe complications after liver resection using an AggRCA.Methods: This was a retrospective qualitative study aimed to identify the main patterns contributing to severe complications, defined as strictly higher than grade IIIa according to the Clavien-Dindo classification within the first 90 days after liver resection. All consecutive severe complications that occurred between January 1st, 2018 and December 31st, 2019 were identified from an electronic database and included in an AggRCA. This included a structured morbidity and mortality review (MMR) reporting tool based on 50 contributory factors adapted from 6 ALARM categories: “Patient”, “Tasks”, “Individual staff”, “Team”, “Work environment”, and “Management and Institutional context”. Data resulting from individual-participant root cause analysis (RCA) of single-cases were validated collectively then aggregated. The main patterns were suggested from the contributory factors reported in more than half of the cases.Results: In 105 consecutive liver resection cases, 15 patients (14.3%) developed severe postoperative complications, including 5 (4.8%) who died. AggRCA resulted in the identification of 36 contributory factors. Eight contributory factors were reported in more than half of the cases and were compiled in three entangled patterns: (1) Disrupted perioperative process, (2) Unplanned intraoperative change, (3) Ineffective communication.Conclusion: A pragmatic aggregated RCA process improved our understanding of system vulnerabilities based on the analysis of a limited number of events and a reasonable resource intensity. The identification of patterns contributing to severe complications lay the rationale of future contextualized safety interventions beyond the scope of liver resections.

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“…activities) and ‘outcomes’ (results) [ 22 ]. Four measurement methods are presented in the following section that gauge mutually complementary aspects of patient safety issues (see Table 1 ) [ 1 ▪▪ , 24 , 25 ▪ , 26 ▪ , 27 – 37 , 38 ▪ , 39 , 40 – 56 ].…”

Section: Practical Approaches To Measuring and Monitoring Perioperatimentioning

confidence: 99%

“…Analysis of reports using structured protocols and root cause analysis (e.g., the ‘London Protocol’ [ 12 , 58 ]) may reveal local system weaknesses, and allow tailoring of local solutions [ 26 ▪ ]. As root cause analysis is time-consuming and labour-intensive, more rapid but less in-depth alternative techniques have been described, which should be combined according to the context [ 25 ▪ ]. If specific incident patterns are frequently observed, or reveal important risks, locally adapted safety indicators can be developed and used for rate-based measurements.…”

Section: Practical Approaches To Measuring and Monitoring Perioperatimentioning

confidence: 99%

Measuring and monitoring perioperative patient safety: a basic approach for clinicians

Wacker

2020

Current Opinion in Anaesthesiology

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Purpose of review Recent research points to considerable rates of preventable perioperative patient harm and anaesthesiologists’ concerns about eroding patient safety. Anaesthesia has always been at the forefront of patient safety improvement initiatives. However, factual local safety improvement requires local measurement, which may be afflicted by barriers to data collection and improvement activities. Because many of these barriers are related to mandatory reporting, the focus of this review is on measurement methods that can be used by practicing anaesthesiologists as self-improvement tools, even independently from mandatory reporting, and using basic techniques widely available in most institutions. Recent findings Four mutually complementary measurement approaches may be suited for local patient safety learning: incident and rate-based measurements, staff surveys and patient surveys. Reportedly, individual methods have helped to tailor problem solutions and to reduce patient harm, morbidity, and mortality. Summary Considering the potential for perioperative patient safety measurements to improve patient outcomes, the absence of a generally accepted measurement standard and manifold barriers to reporting, a pragmatic approach to locally measuring patient safety appears advisable.

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Review of alternatives to root cause analysis: developing a robust system for incident report analysis

Cited by 25 publications

References 89 publications

Contributing factors to severe complications after liver resection: an aggregate root cause analysis in 105 consecutive patients

Contributing factors to severe complications after liver resection: an aggregate root cause analysis in 105 consecutive patients

Contributing factors to severe complications after liver resection: an aggregate root cause analysis in 105 consecutive patients.

Measuring and monitoring perioperative patient safety: a basic approach for clinicians

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