Presentation
HE1 - Advancing the effectiveness of Root Cause Analysis in Healthcare Serious Safety Event Evaluations
DescriptionHealthcare (HC) root cause analysis (RCA) continues to be largely unable to learn from serious safety events (SSE). When Harm reaches patients, linear descriptions that follow Boolean cause-effect relationships (ie Swiss Cheese Modeling) are inadequate descriptions of the complexity and nuance involved in describing how and why harm reaches patients. Despite significant advances in safety science (Safety-2), HC has perpetuated a broken approach to SSE investigations and has largely not adopted better tools and methods to conduct these types of analyses, leading to a failure in preventing the recurrence of harm after an RCA is completed.
Further complicating RCAs is the relationship between legal, risk, and patient safety, which can be a tenuous one at best. Navigating this balance and understanding the laws of your state is paramount to understanding the reasoning and rationale behind why the hospital has made some of the decisions it has about the RCA processes. I will discuss how and why The relationship between legal, risk, and patient safety are important and how we can work collaboratively with our risk and legal partners to improve the RCA process while maintaining legal protections.
• Having a team interview
• Providing questions to the lawyers for their interview process
• Having the lawyer join the walk-through process
Finally, after having committed many hours of precious time and effort reviewing an SSE, there is not much evidence in the literature for assessing SSE Evaluation effectiveness. Given that most RCAs are conducted by clinicians with little or no training in the safety sciences, evaluating the quality of contributing factors and action items resulting from RCAs can provide important feedback to those staff and inform the design of their training and support structures.
Further complicating RCAs is the relationship between legal, risk, and patient safety, which can be a tenuous one at best. Navigating this balance and understanding the laws of your state is paramount to understanding the reasoning and rationale behind why the hospital has made some of the decisions it has about the RCA processes. I will discuss how and why The relationship between legal, risk, and patient safety are important and how we can work collaboratively with our risk and legal partners to improve the RCA process while maintaining legal protections.
• Having a team interview
• Providing questions to the lawyers for their interview process
• Having the lawyer join the walk-through process
Finally, after having committed many hours of precious time and effort reviewing an SSE, there is not much evidence in the literature for assessing SSE Evaluation effectiveness. Given that most RCAs are conducted by clinicians with little or no training in the safety sciences, evaluating the quality of contributing factors and action items resulting from RCAs can provide important feedback to those staff and inform the design of their training and support structures.
Event Type
Poster Presentation
TimeTuesday, March 264:45pm - 6:15pm CDT
LocationSalon C
Digital Health
Simulation and Education
Hospital Environments
Medical and Drug Delivery Devices
Patient Safety Research and Initiatives