Root Cause Analysis and 4 hidden layers of Accident Causation Model

Root Cause Analysis:

There is the root cause analysis, which is a main corner for medical errors, we are going to go a little bit in some detail about what we mean by RCA or the root cause analysis, this is an approach for identifying the original causality of the error so that we can find permanent solution and apply it. So we it’s a way to analyze the problem, the error, so that we can develop the default / enhanced system, and improve the chances of dealing with these problems in the future.

We have been introduced to the Accident Causation Model or as known as “Swiss Cheese Model“, basically, it’s talking about four layers and three layers before the appearance of the error.

First

The acts of failure, for example, there are unsafe acts committed by the people who are in direct contact with the patient or the system, for example, slips and lapses. That’s to say that the errors in the task execution or errors in planning, this is the very definition of medical error, there is error in the planning or in the execution of the plan, just to say that we had the other wrong plan or the right language, but it’s executed in the wrong way. So, this is an act of failure.

Second

It could be a procedural violation, which is basically a rule breaking. So for example, we know that we have to wash our hands at certain size. But the healthcare professional intentionally breaks this or violates this rule. For example, He did not adhere to hand washing, although the infection control measures…etc. So, these are the act of failures.

Third

There are also what are known as the error producing conditions. By error producing conditions, we mean that there are conditions within the local workplace, for example, the time pressure, the understaffing, inadequate equipments, the fatigue of the staff, and the inexperience of the staff.

Fourth

And there are also the latent failures, which are basically decisions, made by policymakers, leaders and top level management.

So all of these are kind of the categorization of the factors that could lead to a medical error these are referred to as reasons accident causation model.

What do you mean by the root cause analysis?

It is an official process of investigation aimed at identifying the root causes of negative adverse effects. So it is an official process that should be taken and it is a requirement by accreditation bodies. The aim is to evaluate, analyze and develop system improvements. Again, the RCA aims at the system, not the individuals not excluding the individuals, but the main the aim the focus is on the systems.

So the RCA focus on the systems are not the individual workers with the assumption that adverse event is a system failure, we assume that error in a part of it in a big part of it is a system related failure. So we need to adjust the system rather than blame and shame culture of individuals who were involved in the error itself. The accredited hospitals must report all serious accidents by RCA and work plan to eliminate the risk within 30 days from the date of serious accident notes. So it is an official requirement for any hospital to make such a report.

To make a proper RCA, what do we need to know?

First, what happened? What was the problem? What is the incident?

For example, a medication was given in the wrong dose? The surgical operation was done on the wrong side, etc. and any other example of medical errors, who was involved?

Then, when did it happen? Where did it happen? And the severity of the actual or potential harm, if the harm could have happened, the severity of it, we need to define it. For example, was it just a few days more of admission or loss of function or loss of a limb, etc? And what is the likelihood of recurrence? How likely is this medical error to happen again? And what are the consequences of what had happen? So the RCA focuses on this things are not individual words, we say this again and again, it’s assumed that this event, as we said, is a system failure rather than a problem of a person. And it is important to report this as we have just mentioned, this is a requirement for all accredited hospitals.

You can visualize a root cause analysis with what is called the fishbone model, but there are other models.

Previous extension of this post …

We’re going to talk about the prevention and management of medical errors. 

Previous extension of this post …

Medication errors 101.