Root Cause Analysis and Actions for the Prevention of Medical Errors: Quality Improvement and Resident Education

Abstract

The quality of care delivered by orthopedic surgeons continues to grow in importance. Multiple orthopedic programs, organizations, and committees have been created to measure the quality of surgical care and reduce the incidence of medical adverse events. Structured root cause analysis and actions (RCA2) has become an area of interest. If performed thoroughly, RCA2 has been shown to reduce surgical errors across many subspecialties. The Accreditation Council for Graduate Medical Education has a new mandate for programs to involve residents in quality improvement processes. Resident engagement in the RCA2 process has the dual benefit of educating trainees in patient safety and producing meaningful changes to patient care that may not occur with traditional quality improvement initiatives. The RCA2 process described in this article can provide a model for the development of quality improvement programs. In this article, the authors discuss the history and methods of the RCA2 process, provide a stepwise approach, and give a case example. [Orthopedics. 2017; 40(4):e628-e635.].

Improvement of patient satisfaction by root cause analysis in health care services for urban slum community in North India

“…[ 10 11 12 ] Root cause analysis is a management technique that has been utilized in various studies to understand the depth of the problem. [ 13 14 15 ] Similarly in this root cause analysis, we were able to delineate such factors that require attention and need a focused approach for solutions for an efficient, affordable primary health care practice.…”

Avoiding pressure injuries with Root Cause Analysis and Action

“…The RCA squared process is one way to identify patient safety issues and develop meaningful systems-based improvement initiatives. 1,5 The perioperative skin assessment project implemented by staff members at JMH demonstrated that the return on investment for prevention is worth the effort.…”

“…2 The RCA squared process is used to identify system vulnerabilities and causal factors in an event and determine stronger actions to effectively reduce risk. 1,2 Using the RCA squared process, team members at John Muir Health (JMH) in Concord, California, were able to effectively develop and implement a nurse-driven quality improvement project focused on perioperative pressure injuries and cost-neutral strategies for prevention.…”

“…To achieve this goal, the facility culture must promote honest and open reporting of adverse events and near misses while avoiding blame and punishment of staff members. 1,2 Pressure injuries are a notable harm that can occur in any surgical patient, during any procedure, and in any patient position. 3 Prevention is key for the continuum of patient care, starting before surgery and extending all the way through the patient's stay in the health care system.…”

Patient Safety/Quality Improvement Primer, Part II: Prevention of Harm Through Root Cause Analysis and Action (RCA2)

“…33,34 The initial flow diagram ( Figure 2) is produced to show the chain of events preceding the incident. 35 Trigger questions are used to identify areas of inquiry that may otherwise be overlooked. 36,37 Individuals working in areas identified and outlined on the flow diagram are interviewed to elucidate specifics related to the surroundings, events that transpired, and the potential ''why.''…”