Using simulation to improve root cause analysis of adverse surgical outcomes

Abstract

The use of simulation for investigation of adverse surgical outcomes is feasible and identifies causes that may be more amenable to effective systems changes than conventional RCA. The information that SAO provides may facilitate the implementation of corrective measures, decreasing the risk of recurrence and improving patient safety.

Simulation research to enhance patient safety and outcomes: recommendations of the Simnovate Patient Safety Domain Group

“…This paper has discussed the need for greater incorporation of simulation into the concept of learning healthcare systems to maximise the clinical impact of simulation-based interventions. Evidence for the feasibility of using simulation across the full spectrum of education,41 assessment,42 crisis response19 and quality improvement43 is now emerging. Integrating each of these into a single responsive framework will enable simulation to act as a powerful adjunct to current systems of adverse event reporting, analysis and avoidance.…”

“…When sentinel events do occur, simulation also offers a potentially more effective means of analysis compared with current standard practice. In one of the few such studies conducted thus far in healthcare, adverse events extracted from on-going medical malpractice claims were analysed and scripted, and repeatedly reproduced in a simulated clinical environment 19. Compared with the conventional root cause analysis used in the malpractice claims, repeated simulation was better able to identify system-based errors as opposed to discrete process errors committed by individuals.…”

Using Simulation Technology and The Root Cause Analysis Process to Assess Nurse’s Attitude toward Patient Safety

“…These nurses implied that the use of simulation was preferred to the didactic courses typically used to teach RCA, because they were allowed to actively participate in the sessions and freely communicate their opinions during the debriefing process. Since TJC mandates that RCAs are conducted after every sentinel event, nurse managers and clinical educators should provide routine RCAs to improve patient safety by identifying and preventing potential problems in real time [14]. Using In-situ simulation to guide RCA sessions may be an effective tool for this process, and these benefits may last as long as six months post-training.…”

Using Simulation to Improve Systems

“…22 The use of simulated scenarios and the TeamSTEPPS philosophy has also been successfully applied to root cause analysis (RCA) of adverse events within the operating room. 23,24 Before simulation, RCA at this institution was done retrospectively and with a bias toward identifying errors made by individuals rather than systemic error, correction of which holds far greater promise for improving quality, safety, and cost. By recreating as many variables as possible within a dedicated simulation facility and by involving and empowering all involved parties (surgeon, anesthesiologist, nurses, technicians, and residents), this experiment in recreating an RCA event identified several options for improvement in patient flow and staff distribution; corrections to systems-based errors rather than individual errors.…”