AHRQ Project: Advancing Patient Safety in Rural Areas
Tools and Decision-Making Aids
Root Cause Analysis Factors
A Six-step Approach to Assess Sources of Medical Errors and Success
Cases of errors do not stem from one cause alone, but result from a set of contributing factors. As we look at these cases, we encourage you to examine the threads or sources of medical errors, presented below. They will encourage us to look past the easy answers - such as who is to blame - and focus our attention as to why the various problems occurred and what set of factors contributed to those problems. As you start thinking about these cases, you will probably find that there were several factors involved. Of course, there will be questions that you do not have adequate information, but for the purposes of this task, you may pose hypothetical answers, drawing on experiences from you own organization.
We have adapted this system from the National Center for Patient Safety Handbook, April 2001. At this point it seems to be one of the most developed systems using the new approaches and ways of thinking that help us understand why errors occur and also what constitutes successful solutions.
Triage Questions Starting Point
- Human Factors - Communication. Where issues related to patient assessment, lack of information or misinterpretation a factor in this event?
- Was the patient correctly identified?
- Did all members of the healthcare team have sufficient information about the care plans?
- Was there sufficient documentation for treatment?
- Was communication among staff adequate and correct?
- Were policies and procedures communicated adequately?
- Were there methods for monitoring the adequacy of staff communication?
- Were there obstacles that prevented clear communication or identification of risk factors?
- Did the management provide adequate methods to ensure easy and timely access to information?
- Did the culture of the facility encourage observations and suggestions about "early warnings" or "risky" situations? (Has this happened before, could this happen again?)
- Was there adequate communication between the different departments and organizational boundaries (e.g., prescription recalls)?
- Were family members actively involved in treatment planning?
- Did the overall culture welcome "early warning" signs?
- Human Factors - Training. Where issues related to staff training or competency a factor in this event?
- Was there a program to identify staff program needs?
- Was training provided prior to the start of the work process?
- Were the results of training monitored over time?
- Was training adequate?
- Was training program provided "up-front" so that tasks would be completed without error?
- Was staff trained to understand risk factors?
- Was there a match between staff and assigned tasks?
- Human Factors - Fatigue/Scheduling. Where stress, fatigue, conflict in scheduling, staffing issues or environmental distractions factors in this event?
- Did personnel have adequate sleep?
- Did the schedule allow time for adequate sleep?
- Was the environment free of distractions?
- Was there sufficient staff on hand for the workload?
- Environment, Equipment - Was equipment involved in this event in any way?
- Were the work environment stress levels (either physical or psychological) appropriate? This includes space, noise, intra-facility transfers, physical and psychological.
- Was the equipment designed to reduce the likelihood of mistakes?
- Rules, Policies, Procedures - Was there a lack of appropriate rules/policies/procedures that was a factor in this event?
- Was there an overall management plan for addressing risk and assigning responsibility for risk?
- Was there a quality control system that shows how the processes related to adverse events are functioning?
- Had a similar event occurred?
- Could this problem have gone unidentified or uncorrected?
- Was the staff involved in this situation properly qualified and trained to perform their functions?
- Was all staff oriented to the job, facility, and unit policies?
- Were there written up-to-date policies and procedures that addressed the work processes related to this event?
- Were relevant policies and procedures actually used on a day-to-day basis?
- If the policies were not used, what positive or negative incentives were absent
- Protective Barriers -- Was failure of a barrier designed to protect the patient, staff, equipment or environment a factor in this event?
- What kind of protective processes does the hospital use to prevent such a problem?
- Had these processes ever been evaluated?
- Would this event have been prevented if protective barriers had functioned accurately?
- Were protective processes tested before they were implemented
Additional Questions to Think About
- Could these problems occur in your hospital?
- What systems checkpoints are already in place in your hospital to prevent errors such as these? Will they reduce the likelihood that similar errors will be repeated?
- What are the obstacles to those checkpoints?
- What information/education would help staff change their clinical practice to prevent this error?
