Root Cause Analysis Using the Prevention and Recovery Information System for Monitoring and Analysis Method in Healthcare Facilities: A Systematic Literature Review

Driesen, Babiche E. J. M.; Baartmans, Mees; Merten, Hanneke; Otten, René; Walker, Camilla; Nanayakkara, Prabath W.B.; Wagner, Cordula

doi:10.1097/pts.0000000000000925

Cited by 6 publications

(4 citation statements)

References 50 publications

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“…Driessen and colleagues recently presented a literature review on the use of the Prevention and Recovery Information System for Monitoring and Analysis (PRISMA) method for health care institutions [ 10 ]. The application of PRISMA provides a root cause analysis of factors such as unplanned ICU admissions [ 11 ].…”

Section: Resultsmentioning

confidence: 99%

At the Crossroads of Minimally Invasive Mitral Valve Surgery—Benching Single Hospital Experience to a National Registry: A Plea for Risk Management Technology

Cocchieri

Wetering

Tuijl

et al. 2022

JCDD

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Almost 30 years after the first endoscopic mitral valve repair, Minimally Invasive Mitral Valve Surgery (MIMVS) has become the standard at many institutions due to optimal clinical results and fast recovery. The question that arises is can already good results be further improved by an Institutional Risk Management Performance (IRMP) system in decreasing risks in minimally invasive mitral valve surgery (MIMVS)? As of yet, there are no reports on IRMP and learning systems in the literature. (2) Methods: We described and appraised our five-year single institutional experience with MIMVS in isolated valve surgery included in the Netherlands Heart Registry (NHR) and investigated root causes of high-impact complications. (3) Results: The 120-day and 12-month mortality were 1.1% and 1.9%, respectively, compared to the average of 4.3% and 5.3% reported in the NHR. The regurgitation rate was 1.4% compared to 5.2% nationwide. The few high-impact complications appeared not to be preventable. (4) Discussion: In MIMVS, freedom from major and minor complications is a strong indicator of an effective IRMP but remains concealed from physicians and patients, despite its relevance to shared decision making. Innovation adds to the complexity of MIMVS and challenges surgical competence. An IRMP system may detect and control new risks earlier. (5) Conclusion: An IRMP system contributes to an effective reduction of risks, pain and discomfort; provides relevant input for shared decision making; and warrants the safe introduction of new technology. Crossroads conclusions: investment in machine learning and AI for an effective IRMP system is recommended and the roles for commanding and operating surgeons should be considered.

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Section: Resultsmentioning

confidence: 99%

At the Crossroads of Minimally Invasive Mitral Valve Surgery—Benching Single Hospital Experience to a National Registry: A Plea for Risk Management Technology

Cocchieri

Wetering

Tuijl

et al. 2022

JCDD

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“…Another strength of this study is that patients’ medical records were analyzed completely and objectively by trained multidisciplinary medical professionals, which enabled the acquisition of diverse insights concerning unplanned events that involve different aspects of healthcare and different healthcare professionals [ 29 , 54 ]. The PRISMA method itself is another strength of this study, as it provides in-depth insight into healthcare interventions on a larger scale [ 54 ], and systematic analysis of unplanned events could indicate organizational safety flaws [ 54 ]. The reliability was ensured by the individual assessment of data by qualified and PRISMA trained medical professionals.…”

Section: Discussionmentioning

confidence: 99%

The effect of family-centered care on unplanned emergency room visits, hospital readmissions and intensive care admissions after surgery: a root cause analysis from a prospective multicenter study in the Netherlands

Kreca,

Albers,

Musters

et al. 2024

Patient Saf Surg

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Background Optimizing transitional care by practicing family-centered care might reduce unplanned events for patients who undergo major abdominal cancer surgery. However, it remains unknown whether involving family caregivers in patients’ healthcare also has negative consequences for patient safety. This study assessed the safety of family involvement in patients’ healthcare by examining the cause of unplanned events in patients who participated in a family involvement program (FIP) after major abdominal cancer surgery. Methods This is a secondary analysis focusing on the intervention group of a prospective cohort study conducted in the Netherlands. Data were collected from April 2019 to May 2022. Participants in the intervention group were patients who engaged in a FIP. Unplanned events were analyzed, and root causes were identified using the medical version of a prevention- and recovery-information system for monitoring and analysis (PRISMA) that analyses unintended events in healthcare. Unplanned events were compared between patients who received care from family caregivers and patients who received professional at-home care after discharge. A Mann-Whitney U test was used to analyze data. Results Of the 152 FIP participants, 68 experienced an unplanned event and were included. 112 unplanned events occurred with 145 root causes since some unplanned events had several root causes. Most root causes of unplanned events were patient-related factors (n = 109, 75%), such as patient characteristics and disease-related factors. No root causes due to inadequate healthcare from the family caregiver were identified. Unplanned events did not differ statistically (interquartile range 1–2) (p = 0.35) between patients who received care from trained family caregivers and those who received professional at-home care after discharge. Conclusion Based on the insights from the root-cause analysis in this prospective multicenter study, it appears that unplanned emergency room visits and hospital readmissions are not related to the active involvement of family caregivers in surgical follow-up care. Moreover, surgical follow-up care by trained family caregivers during hospitalization was not associated with increased rates of unplanned adverse events. Hence, the concept of active family involvement by proficiently trained family caregivers in postoperative care appears safe and feasible for patients undergoing major abdominal surgery.

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“…Human and organizational factors are known to be the most frequently identified causes in SE or adverse event studies. 8 , 31 , 32 Not many contributing factors were identified that related to the physical and external environment. A possible explanation could lie in the fact that traditional root cause analysis methods do not or only limitedly address these domains and thus may be underreported in the SE reports.…”

Section: Discussionmentioning

confidence: 99%

“…Aggregated cross-hospital SE analysis using the GAM indicates that a majority of contributed factors were related to the persons and organization domains. Human and organizational factors are known to be the most frequently identified causes in SE or adverse event studies 8,31,32 . Not many contributing factors were identified that related to the physical and external environment.…”

Section: Discussionmentioning

confidence: 99%

Using the Generic Analysis Method to Analyze Sentinel Event Reports Across Hospitals: A Retrospective Cross-Sectional Study

Baartmans

Schoten²,

Smit

et al. 2023

J Patient Saf

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Objectives Improving patient safety by investigating sentinel events (SEs) is hampered by the focus on isolated events within hospitals and a narrow scope of traditional root cause analysis methods. We aimed to examine if performing cross-hospital aggregate analysis of SEs applying a novel generic analysis method (GAM) bearing a human factor perspective can enhance learning from SEs. Methods A retrospective cross-sectional review of SE reports from 28 Dutch general hospitals using the GAM to reanalyze events was performed. A qualitative approach was used to identify contributing factors and system issues. Findings were discussed with a patient safety expert panel. Descriptive statistics and measures of associations between domains were calculated. Results Sixty-nine SE reports were reviewed. Applying the GAM provided a more holistic SE analysis than a traditional method. Of the 405 identified contributing factors in all SEs, the majority was related to the persons involved (patients and professionals, n = 146 [36.2%]) and the organization (n = 121 [30%]). The most frequently recurring pattern was the combination of factors related to the persons involved, the technology used, the tasks of professionals, and organizational factors influencing the event. Cross-hospital aggregate GAM analysis of SEs helped to identify system issues and propose more system-oriented overarching recommendations. Conclusions This study found that applying the GAM to analyze SEs across hospitals can help to improve learning from SEs and may result in proposing stronger recommendations. The method can support hospitals, working together in a network of hospitals, to jointly learn from SEs.

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Root Cause Analysis Using the Prevention and Recovery Information System for Monitoring and Analysis Method in Healthcare Facilities: A Systematic Literature Review

Cited by 6 publications

References 50 publications

At the Crossroads of Minimally Invasive Mitral Valve Surgery—Benching Single Hospital Experience to a National Registry: A Plea for Risk Management Technology

At the Crossroads of Minimally Invasive Mitral Valve Surgery—Benching Single Hospital Experience to a National Registry: A Plea for Risk Management Technology

The effect of family-centered care on unplanned emergency room visits, hospital readmissions and intensive care admissions after surgery: a root cause analysis from a prospective multicenter study in the Netherlands

Using the Generic Analysis Method to Analyze Sentinel Event Reports Across Hospitals: A Retrospective Cross-Sectional Study

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