Root-cause analysis: swatting at mosquitoes versus draining the swamp

Trbovich, Patricia; Shojania, Kaveh G

doi:10.1136/bmjqs-2016-006229

Cited by 79 publications

(94 citation statements)

References 20 publications

(27 reference statements)

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“…This makes designing strong recommendations challenging when the root causes are not entirely clear. Second, it has been suggested that RCA teams made up of health‐care providers do not have the expertise in human factors engineering to develop effective, robust interventions . There are many validated tools available to assist teams with identifying contributing factors to clinical incidents, but little structure or guidance is available to support the development of strong recommendations .…”

Section: Discussionmentioning

confidence: 99%

“…There are many validated tools available to assist teams with identifying contributing factors to clinical incidents, but little structure or guidance is available to support the development of strong recommendations . This is compounded by the fact that the underlying ‘system’ problems that RCAs seek to uncover are often the most difficult problems to solve . Finally, some studies have found that staff do not feel empowered to suggest recommendations that cannot be addressed at the local level .…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Implementation and strength of root cause analysis recommendations following serious adverse events involving paediatric patients in the Queensland public health system between 2012 and 2014

Hamilton

McEniery

Osborne

et al. 2018

J Paediatrics Child Health

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Aim This study evaluates the implementation rate and strength of the recommendations developed in all root cause analyses (RCAs) performed following serious clinical incidents involving children that have resulted in permanent harm or death in Queensland public hospitals over a 3‐year period. Methods Severity assessment classification 1 events were identified from a Queensland Paediatric Quality Council database of paediatric clinical incidents that occurred in Queensland between 1 January 2012 and 31 December 2014. There were 150 recommendations extracted from RCAs pertaining to the 42 serious adverse events involving paediatric patients. Results Of the recommendations, 82% were implemented; 33% of recommendations were classified as stronger, 33% as intermediate and 34% weaker in terms of their potential to improve patient safety. Conclusions This study describes the implementation of recommendations and classifies them in terms of potential to prevent patient harm and save lives. Future research is needed to determine if the RCA process does indeed prevent harm.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Implementation and strength of root cause analysis recommendations following serious adverse events involving paediatric patients in the Queensland public health system between 2012 and 2014

Hamilton

McEniery

Osborne

et al. 2018

J Paediatrics Child Health

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“…Our work demonstrates the complex and time-consuming nature of ADE diagnoses and their categorizations that must be reflected in the design of reporting systems in order to render ADE reporting feasible. Initiatives aimed at improving ADE reporting would likely benefit from a similar paradigm shift as the patient safety movement, which has moved away from a culture of individual blame towards system-level analysis to examine and improve organizational structures and technology design to improve safety [32,33].…”

Section: Discussionmentioning

confidence: 99%

Why Clinicians Don�t Report Adverse Drug Events: Qualitative Study (Preprint)

Hohl¹,

Small²,

Peddie³

et al. 2017

Preprint

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(248/450)Background: Adverse drug events (ADEs) are unintended and harmful events related to medications. ADE outcomes are important for patients, quality improvement, drug safety research, and post-marketing surveillance; yet they are vastly underreported. Objective: Our objectives were to identify barriers to ADE documentation and factors contributing to underreporting. Methods: This qualitative study was conducted in one ambulatory centre and three hospitals in British Columbia between March 2014 and December 2016. We completed workplace observations and focus groups with family, hospitalist and emergency physicians, and hospital and community pharmacists. We analyzed field notes by coding and iteratively analyzing our data to identify emerging concepts, generate thematic and event summaries, and create workflow diagrams. Clinicians validated emerging concepts by applying them to cases from their clinical practice. Results: We completed 238 hours of observations during which clinicians investigated 65 suspect ADEs. The observed events were often complex and diagnosed over time, requiring the input of multiple providers. Providers documented ADEs in charts to support continuity-of-care, but never reported them to external agencies. Providers faced time constraints, and reporting would have required duplication of documentation. Conclusions: Existing reporting systems are not suited to capture the complex nature of ADEs nor adapted to workflow, and simply not used by frontline clinicians. Systems that are integrated into electronic medical records (EMRs), make use of existing data to avoid duplication of documentation, and generate alerts to improve safety may address the shortcomings of existing systems, and generate robust ADE data as a byproduct of safer care.

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“…To illustrate, complaints about a brusque doctor or a nurse not responding to call bells in a timely manner could reflect the typical behaviour of that clinician but could also reflect problems with problematic workload or conflicting expectations of staff. A tendency to view the individual provider as the problem that needs fixing fails to identify underlying system factors17 and could also unnecessarily damage healthcare professionals. While it has been shown that a small number of physicians account for a large proportion of complaints,18 we cannot rule out whether these providers were more prone to complaints due to a larger volume of patients or more difficult patients,16 19 such as patients with a greater risk of complications and hence of complaints 20.…”

Section: Difficulties Identifying the Improvement Strategy And Targetmentioning

confidence: 99%

“…Yet some colleagues may be reluctant to report problems with a fellow clinician 29–31. Therefore, additional investigation will likely be required to assess whether problems raised in complaints are also reflected in other available sources of information, such as interviews with complainants and providers, direct observation of care,17 or review of response letters and medical records. Moreover, hospitals could use triangulation with other data from the clinician or patient perspective, such as quantitative outcome or patient experience data (eg, National Surgical Quality Improvement Program [NSQIP] or Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS]), but even then it will remain extremely difficult to identify and solve the actual system problems, a process that requires substantial work and investments 17…”

Section: From Isolation To Integrationmentioning

confidence: 99%