Medical Errors and the United States Healthcare System _ ___________________________________________
at the systemic level, improving performance and reducing the likelihood of another sentinel event. Failure to perform an RCA within 45 days of the occurrence of a sentinel event may result in the healthcare institution being placed on an ‘accreditation watch,’ which is public information. Repeat violations may result in an onsite review by the Joint Commis- sion that may jeopardize accreditation. The Joint Commission has created a framework and series of 24 questions to aid in organizing an RCA. This framework is recommended to be used as a general template when preparing the RCA report that will eventually be submitted to the Joint Commission after thorough evaluation [26]. The 24-question framework recommended by the Joint Commission considers a variety of situational factors that may have contributed to a sentinel event. This includes examining the systematic process, human factors, equipment malfunctions, environmental factors, uncontrollable external factors, organizational factors, staffing and qualifications, contingency plans, performance expectations, informational disruptions, communication, environmental risks, training, and technology (Table 1) [26]. Prevention strategies typically address the three most com- mon causes of medical errors: communication, planning and knowledge, and systemic or institutional failure.
ROOT CAUSE FACTORS THAT CONTRIBUTE TO MEDICAL ERRORS The causes and prevention of medical errors are the focus of considerable academic and professional attention. For accreditation purposes, the Joint Commission requires that healthcare institutions have a comprehensive process for the systematic analysis of sentinel events [26]. Reporting of sen- tinel events by accredited organizations is voluntary, and it is estimated that less than 2% of all sentinel events that occur in healthcare are reported to The Joint Commission. The most frequently reported sentinel events in 2020 were fall (n=170), unintended retention of a foreign object (n=106); suicide (n=81); delay in treatment (n=76); wrong side-surgery (n=68); assault/rape/sexual assault (n=47); fire (n=30); clinical alarm response (n=27); self-harm (n=24); and medication manage- ment (n=24) [27]. The Office of Quality and Patient Safety at The Joint Commission works with organizations reporting sentinel events to identify contributing factors and actions the organization can take to reduce risk [27]. The root cause analysis (RCA) process is one of the most commonly used tools by institutions to optimize patient care and enact measures to mitigate adverse events. RCA is pri- marily based on system-level process. The RCA starts with a designated team that reviews and identifies required changes
24 ANALYSIS QUESTIONS FROM THE JOINT COMMISSION FRAMEWORK FOR ROOT CAUSE ANALYSIS AND CORRECTIVE ACTIONS [27].
2. Did staff performance during the event meet expectations? 4. To what degree was all the necessary information available when needed? 5. Accurate? Complete? Ambiguous? 7. To what degree is communication among participants adequate? 9. Was this the appropriate physical environment for the processes being carried out? 11. What systems are in place to identify environmental risks? 13. What emergency and failure-mode responses have been planned and tested? 15. How does the organization’s culture support risk reduction? 17. What are the barriers to communication of potential risk factors? 19. How does leadership address the continuum of patient safety events, including close calls, adverse events, and unsafe, hazardous conditions? 21. How can orientation and in-service training be improved?
1. What was the intended process flow?
3. Were there any steps in the process that did not occur as intended?
6. What human factors were relevant to the outcome?
8. How did the equipment performance affect the outcome?
10. What controllable environmental affected the outcome?
12. What uncontrollable external factors influenced the outcome?
14. Were there any other factors that directly influenced this outcome? 16. What are the other areas in the healthcare organization where this could happen? 18. Was staff properly qualified and currently competent for their responsibilities?
20. How did actual staffing compare with ideal level?
22. What is the plan for dealing with staffing contingencies?
23. Was available technology used as intended?
[Source: 27]
Table 1
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MDFL0627
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