● Physical causes: Material items failed in some way (equipment fails). ● Human causes: Someone did not do something that was needed or did something incorrectly (individual improperly uses equipment). ● Organizational causes: A system, process, or policy is faulty (no single person is responsible for equipment maintenance). Analysis of the incident is generally divided into: ● Data collection: Establishment of what happened through structural interviews, document review, and/or field observation. This provides a time line of events before and following the event. ● Data analysis: Examination of the sequence of events generated to determine the common underlying factors. This includes examining both active and latent failures in the sequence (AHRQ, 2001). At the conclusion of the root cause analysis, the team summarizes the underlying causes and their relative contributions and develops an action plan to address the identified deficits. Sentinel event forms and tools to assist in conducting a root cause analysis and action plan are available on the Joint Commission’s website (http://www. jointcommission.org/topics/patient_safety.aspx).
recurrence. Root cause analysis is done after an error occurs and is designed to uncover problems that resulted in an adverse patient event. The process of root cause analysis looks beyond the immediate result and strives to identify the chain of events and contributing factors that led to the error. The purpose is to identify what happened, why it happened, and what can be done to prevent it from happening again, by examining both the active and latent errors that occurred. Root cause analysis is based on the premise that most human errors are fostered by system failures, and that personal blame is less helpful than assessing how to prevent future errors (TJC, 2010). Since 1997, the Joint Commission has required that a root cause analysis be conducted for each reported sentinel event – that is, an event that resulted in death or physical or psychological injury (TJC, 2013). The Joint Commission standards require that a root cause analysis be thorough and credible. Table 1 summarizes the requirements for a thorough and credible root cause analysis. Experts from all areas involved in the adverse event and those individuals who are familiar with the situation should be included in the process. The main premise of root cause analysis is that systems and events are interrelated. An action in one area triggers an action in another. The basic types of root causes include:
Table 1: Criteria for Root Cause Analysis To be thorough, a root cause analysis must include: ● Determination of human and other factors most directly associated with adverse events or close calls. ● Analysis of underlying cause and effect systems through a series of why questions to determine where redesigns might reduce risk. ● Identification of risks and their potential contributions to the adverse event or close call. ● Determination of potential improvement in processes or systems that would decrease the likelihood of such events in the future, or a determination, after analysis, that no such improvement opportunities exist. To be credible, a root cause analysis must: ● Include participation by the leadership of the organization and those most closely involved in the processes and systems under review. ● Be internally consistent. ● Include consideration of relevant literature. ● Include corrective outcome measures and top management approval. Note: Adapted from the U.S. Department of Veterans Affairs, VA National Center for Patient Safety. (2014b). Root cause analysis. Retrieved from http://www.patientsafety.va.gov/professionals/onthejob/rca.asp Reporting medical/dental errors
A major recommendation of the landmark HMD report was that voluntary reporting systems be developed for adverse events that result in minimal or no harm, and that a mandatory reporting system be established for errors that result in permanent injury or death. Although mandatory reporting at the national level has not been realized, several excellent voluntary systems exist and are described below. Several states have enacted mandatory reporting programs. Florida’s program is discussed as an example of a state program. The Joint Commission The Joint Commission encourages, but does not require, the reporting of all sentinel events. The Joint Commission also encourages accredited healthcare facilities to report close calls to help prevent future errors. The Joint Commission collects and analyzes data from the review of sentinel events, root cause analyses, and risk reduction measures that healthcare organizations submit (TJC, 2013). Between January 1, 1995, and June 30, 2010, the Joint Commission reviewed 6,923 sentinel events (TJC, 2014). Most sentinel events occurred in hospitals. Sixty-seven percent (4,642) resulted in patient death. Wrong-site surgery was the most common sentinel error, accounting for about 13% of all reported events (TJC, 2014). All data submitted are confidential. This information makes up the Joint Commission’s sentinel event database, which is also a major component of the evidence base for the National Patient Safety Goals (TJC, 2014, 2017b). The Sentinel Event Alert
is an online report that identifies sentinel events, describes their common causes, and suggests actions to prevent these occurrences. It is available at http://www.jointcommission.org/ topics/hai_sentinel_event.aspx Accredited healthcare organizations are expected to: ● Review each alert and consider any relevant information appropriate to the organization’s services. ● Consider information in the alert when designing and redesigning relevant processes. ● Evaluate systems in light of the information in the alert. ● Consider standard-specific concerns. This includes evaluating the Joint Commission standard and contemplating any concern that may stem from the standard wording or interpretation. For example, Sentinel Event – Retained Foreign Object after Surgery raises the question: When exactly is “after surgery”? “After surgery” is any time after completion of the skin closure, even if the patient is still in the operating room under anesthesia. ● Implement relevant suggestions or reasonable alternatives or provide a reasonable explanation for not implementing relevant changes (TJC, 2008). Institute for Safe Medication Practices The Institute for Safe Medication Practices (ISMP) is a nonprofit organization whose mission is to educate the healthcare community, including consumers, about safe medication practices (ISMP, 2010, 2014). The institute directs
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Book Code: DHFL2624
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