Presentation
Implementation of Systemic Contributors and Adaptations Diagramming for Event Review
DescriptionMany patient safety events do not meet the criteria for formal hospital review but impact ongoing safety efforts at the unit level, frequently revealing weaknesses in the local system that put patients at risk. Concise review of these events is likely to strengthen the overall system of care delivery, but individual hospital units may not be sufficiently resourced to undertake standard retrospective event analysis techniques. To meet this need, we have piloted the introduction of an alternate method of event review in the Pediatric Intensive Care Unit (PICU): Systemic Contributors Analysis and Diagram (SCAD) (Jefferies et al., 2022). First utilized by the National Aeronautics and Space Administration (NASA) following a near-miss event in 2013, SCAD identified multiple contributors to a near-fatal event not evident in the RCA performed for the event (Walker et al., 2016). In our PICU, the SCAD technique focuses on identifying pressures in the critical care delivery environment that lead to conflicts and adaptations that contribute to patient safety events. Proponents of this methodology seek to collaborate with Washington University School of Medicine and St. Louis Children’s Hospital to deploy this tool to both promote safer healthcare and advance the field of human factors and resilience engineering.
Similar to many hospitals, when a serious safety event occurs at St. Louis Children’s Hospital, hospital leaders partner with the unit and proceed with a standard retrospective event analysis, such as an Apparent Cause Analysis (ACA) or a Common Cause Analysis (CCA). For sentinel events, a Root Cause Analysis (RCA) is performed as required by The Joint Commission. RCAs provide structure but may expend considerable resources. These hospital-level event analyses require in-depth chart review and scheduling at least one meeting with multiple individuals involved in the event. Units also define specific triggers for patient safety event review, which may include mortality, return to a higher level of care within 24 hours, or unplanned procedures. These triggers do not usually require hospital-level involvement, but unit-based patient safety specialists expend significant effort creating timelines, reviewing charts, and facilitating meetings. Regrettably, staff and other resource shortages increasingly constrain the number of events to undergo analysis at all, putting the organization at further risk.
It is not uncommon for RCA, ACA, and CCA action items to include those of low to intermediate strength, as described by the National Patient Safety Foundation (NPSF) (2015). The NPSF also notes that recurrence rates may result from intermediate- or weaker-strength action items that focus more on human memory versus actions that take a system-based approach (2015). Following the implementation of many RCA, ACA, and CCA interventions at our institution, we find that events of the same type do regrettably recur. While unfortunate, this phenomenon is not unexpected, as the long-term impact on event recurrence is not clear with the use of RCAs (Kellogg et al., 2016; Wu et al., 2008). Peerally and colleagues (2016), studying the sentinel events most commonly reported to the Joint Commission (falls, wrong-side or wrong-site surgery, and retained foreign objects), noted that while these events occur infrequently, they may indeed recur in the same institution.
While SCAD reviews do not replace hospital-level work via RCAs, ACAs, or CCAs at our institution, we find that the SCAD analysis approach offers the PICU several advantages, including ease of scheduling—a core team performs the work during an established time; less preparation work required as the process is a facilitated discussion; events analyzed are those not typically reported to the Joint Commission; more open discussion—less focus on the individual and more on the environment.
The core SCAD analysis team, consisting of Pediatric Critical Care Medicine faculty, patient safety specialists, and fellows, have used the SCAD tool to review nineteen patient safety events in our PICU. The SCAD process consists of a one-hour facilitated discussion where the SCAD diagram projects on a whiteboard, whereupon open commentary is encouraged in a blame-free environment. Beyond the eleven mortality or cardiopulmonary resuscitation events and two patient morbidity and care escalation events, the remaining events offered opportunities to explore care system processes that did not cause patient injury but were at risk for recurrence and could result in future harm. Facilitators also use SCAD to promote discussion around decision-making removed in space and time from the event as well as endemic blunt-end forces in the system. The core SCAD analysis team develops action items following the discussion and helps facilitate their implementation.
We will share a case study of a SCAD analysis completed when a nurse inadvertently administered an intravenous medication orally. While the patient experienced no harm, the review uncovered medication practices unknown to most bedside staff. The SCAD diagram afforded insight into multiple systemic contributors to the event. These insights, which are qualitatively different than those afforded by RCAs, include how time pressure interacts with the unit’s reliance on the IV team, considerations regarding sucrose and breastmilk, sources of expertise sought out by nurses, and challenges using the medication-dispensing machine requiring previously unappreciated staff adaptations.
Jefferies, C. M., Balkin, E. A., Groom, L., & Rayo, M. F. (2022). Developing Systemic Contributors and Adaptations Diagramming (SCAD): Systemic insights, multiple pragmatic implementations. Proceedings of the 66th Annual International Meeting of the Human Factors and Ergonomics Society, 66, 75–79.
Kellogg, K. M., Hettinger, Z., Shah, M., Wears, R. L., Sellers, C. R., Squires, M., & Fairbanks, R. J. (2016). Our current approach to root cause analysis: Is it contributing to our failure to improve patient safety? BMJ Quality & Safety, bmjqs-2016-005991.
National Patient Safety Foundation (NPSF). (2015). RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. National Patient Safety Foundation. https://www.ihi.org/resources/Pages/Tools/RCA2-Improving-Root-Cause-Analyses-and-Actions-to-Prevent-Harm.aspx
Peerally, M. F., Carr, S., Waring, J., & Dixon-Woods, M. (2016). The problem with root cause analysis. BMJ Quality & Safety, bmjqs-2016-005511.
Walker, K. E., Woods, D. D., & Rayo, M. F. (2016). Multiple Systemic Contributors versus Root Cause: Learning from a NASA Near Miss. Proceedings of the Human Factors and Ergonomics Society Annual Meeting, 60, 264–264.
Wu, A. W., Lipshutz, A. K. M., & Pronovost, P. J. (2008). Effectiveness and efficiency of root cause analysis in medicine. JAMA, 299(6), 685–687.
Similar to many hospitals, when a serious safety event occurs at St. Louis Children’s Hospital, hospital leaders partner with the unit and proceed with a standard retrospective event analysis, such as an Apparent Cause Analysis (ACA) or a Common Cause Analysis (CCA). For sentinel events, a Root Cause Analysis (RCA) is performed as required by The Joint Commission. RCAs provide structure but may expend considerable resources. These hospital-level event analyses require in-depth chart review and scheduling at least one meeting with multiple individuals involved in the event. Units also define specific triggers for patient safety event review, which may include mortality, return to a higher level of care within 24 hours, or unplanned procedures. These triggers do not usually require hospital-level involvement, but unit-based patient safety specialists expend significant effort creating timelines, reviewing charts, and facilitating meetings. Regrettably, staff and other resource shortages increasingly constrain the number of events to undergo analysis at all, putting the organization at further risk.
It is not uncommon for RCA, ACA, and CCA action items to include those of low to intermediate strength, as described by the National Patient Safety Foundation (NPSF) (2015). The NPSF also notes that recurrence rates may result from intermediate- or weaker-strength action items that focus more on human memory versus actions that take a system-based approach (2015). Following the implementation of many RCA, ACA, and CCA interventions at our institution, we find that events of the same type do regrettably recur. While unfortunate, this phenomenon is not unexpected, as the long-term impact on event recurrence is not clear with the use of RCAs (Kellogg et al., 2016; Wu et al., 2008). Peerally and colleagues (2016), studying the sentinel events most commonly reported to the Joint Commission (falls, wrong-side or wrong-site surgery, and retained foreign objects), noted that while these events occur infrequently, they may indeed recur in the same institution.
While SCAD reviews do not replace hospital-level work via RCAs, ACAs, or CCAs at our institution, we find that the SCAD analysis approach offers the PICU several advantages, including ease of scheduling—a core team performs the work during an established time; less preparation work required as the process is a facilitated discussion; events analyzed are those not typically reported to the Joint Commission; more open discussion—less focus on the individual and more on the environment.
The core SCAD analysis team, consisting of Pediatric Critical Care Medicine faculty, patient safety specialists, and fellows, have used the SCAD tool to review nineteen patient safety events in our PICU. The SCAD process consists of a one-hour facilitated discussion where the SCAD diagram projects on a whiteboard, whereupon open commentary is encouraged in a blame-free environment. Beyond the eleven mortality or cardiopulmonary resuscitation events and two patient morbidity and care escalation events, the remaining events offered opportunities to explore care system processes that did not cause patient injury but were at risk for recurrence and could result in future harm. Facilitators also use SCAD to promote discussion around decision-making removed in space and time from the event as well as endemic blunt-end forces in the system. The core SCAD analysis team develops action items following the discussion and helps facilitate their implementation.
We will share a case study of a SCAD analysis completed when a nurse inadvertently administered an intravenous medication orally. While the patient experienced no harm, the review uncovered medication practices unknown to most bedside staff. The SCAD diagram afforded insight into multiple systemic contributors to the event. These insights, which are qualitatively different than those afforded by RCAs, include how time pressure interacts with the unit’s reliance on the IV team, considerations regarding sucrose and breastmilk, sources of expertise sought out by nurses, and challenges using the medication-dispensing machine requiring previously unappreciated staff adaptations.
Jefferies, C. M., Balkin, E. A., Groom, L., & Rayo, M. F. (2022). Developing Systemic Contributors and Adaptations Diagramming (SCAD): Systemic insights, multiple pragmatic implementations. Proceedings of the 66th Annual International Meeting of the Human Factors and Ergonomics Society, 66, 75–79.
Kellogg, K. M., Hettinger, Z., Shah, M., Wears, R. L., Sellers, C. R., Squires, M., & Fairbanks, R. J. (2016). Our current approach to root cause analysis: Is it contributing to our failure to improve patient safety? BMJ Quality & Safety, bmjqs-2016-005991.
National Patient Safety Foundation (NPSF). (2015). RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. National Patient Safety Foundation. https://www.ihi.org/resources/Pages/Tools/RCA2-Improving-Root-Cause-Analyses-and-Actions-to-Prevent-Harm.aspx
Peerally, M. F., Carr, S., Waring, J., & Dixon-Woods, M. (2016). The problem with root cause analysis. BMJ Quality & Safety, bmjqs-2016-005511.
Walker, K. E., Woods, D. D., & Rayo, M. F. (2016). Multiple Systemic Contributors versus Root Cause: Learning from a NASA Near Miss. Proceedings of the Human Factors and Ergonomics Society Annual Meeting, 60, 264–264.
Wu, A. W., Lipshutz, A. K. M., & Pronovost, P. J. (2008). Effectiveness and efficiency of root cause analysis in medicine. JAMA, 299(6), 685–687.
Event Type
Oral Presentations
TimeMonday, March 252:06pm - 2:24pm CDT
LocationSalon A-3
Patient Safety Research and Initiatives