Academic journal article Australian Health Review

Reviewing Recommendations of Root Cause Analyses

Academic journal article Australian Health Review

Reviewing Recommendations of Root Cause Analyses

Article excerpt

Abstract

Objective: To determine the opinion of medical and nursing clinicians of recommendations arising from root cause analyses (RCAs) conducted between 1 April 2003 and 30 September 2004 in one Sydney Area Health Service.

Methods: Twelve doctors (response rate 86%) and 17 nurses (response rate 100%) reviewed 328 recommendations arising from 59 RCAs and completed a self-administered survey.

Results: Nurses were significantly more likely than doctors to rate recommendations made by the original RCA team as "relevant to the causal statement", "understandable", "measurable" and "achievable". Doctors and nurses involved in the original RCA were significantly more likely to state that recommendations would "eliminate" or "control" the risk of a similar event occurring in the future.

Conclusions: This is one of the first studies to analyse RCA data at the area health service level. That nurses reviewed recommendations more favourably may have implications for successful adoption of recommendations at the clinical level. We recommend further detailed analyses of recommendations arising from RCAs in order to determine their usefulness to inform strategies for improved patient safety.

Aust Health Rev 2007: 31(2): 288-295

IN DECEMBER 2002 New South Wales Health and the Institute for Clinical Excellence introduced a new system of incident reporting.1 The Patient Safety Improvement Program,1 based on a successful program developed by the Veterans Health Administration in the United States,2,3 moves from the historical system of reporting of incidents/ adverse events at the local level to a uniform statewide reporting and monitoring system. The aim of the Patient Safety Improvement Program is to identify, report, analyse and act on all incidents, thus making health care safer.4

The Program uses root cause analysis (RCA) as a process to identify systemic causes of incidents that occur in the health system including, where possible, analysis of "near miss" events.1 RCA is a systematic method of analysing an incident or adverse event to determine how and why the event occurred and whether there are steps that could be taken to prevent a recurrence. A severity assessment code (SAC) is assigned to every adverse event by the person reporting the incident. The SAC is confirmed by the direct line manager and again at the area health service level. The SAC codes range from "extreme risk" events such as death (SAC 1) to "low risk events" such as a patient fall or medication error where there was no injury to the patient, no increased care required or increased length of hospital stay (SAC 4). NSW Health has developed a matrix to determine the SAC based on the consequence of the event ("serious", "major", "moderate", "minor" or "minimum") and the likelihood of it recurring ("rare", "unlikely", "possible", "likely" or "frequent").5 SAC 1 adverse events must be reported to NSW Health within 24 hours while SAC 2, 3 or 4 adverse events are reported to NSW Health at the Chief Executive Officers discretion.4

Following allocation of a SAC, a reportable incident brief (RIB) is prepared and forwarded to the appropriate Divisional Head and the General Manager of the facility. The RIB provides initial information about the adverse event and lists further planned immediate action. Following receipt of a RIB, the General Manager of the facility confirms the SAC. RCAs are required for all SAC 1 adverse events, for adverse events likely to attract external attention and for those requiring notification under existing NSW Health legislative reporting requirements that have not been reported via other mechanisms.5

When an RCA is required, a detailed multidisciplinary analysis is conducted to identify the root causes and contributing factors. The RCA team, appointed by senior management, formulate causal statements and make structured recommendations to eliminate, control or accept the risk of a similar event occurring in the future (Box 1). …

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