Making Sense of Root Cause Analysis Investigations of Surgery-Related Adverse Events

2012 ◽  
Vol 92 (1) ◽  
pp. 101-115 ◽  
Author(s):  
Bryce R. Cassin ◽  
Paul R. Barach
Keyword(s):  
Adverse Events ◽  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause ◽  
Making Sense

scholarly journals Root cause analysis applied to the investigation of serious untoward incidents in mental health services

2004 ◽  
Vol 28 (3) ◽  
pp. 75-77 ◽  
Author(s):  
L. A. Neal ◽  
D. Watson ◽  
T. Hicks ◽  
M. Porter ◽  
D. Hill
Keyword(s):  
Mental Health ◽  
Mental Health Services ◽  
Health Services ◽  
Adverse Events ◽  
Root Cause Analysis ◽  
Serious Adverse Events ◽  
Cause Analysis ◽  
Root Cause ◽  
Department Of Health ◽  
Investigative Process

The Department of Health publication Building a Safer NHS for Patients sets out the Government's plans for promoting patient safety (Department of Health, 2001). This follows growing international recognition that health services around the world have underestimated the scale of unintended harm or injury experienced by patients as a result of medical error and adverse events occurring in health care settings. These plans include a commitment to replace the procedures set out in the Department of Health circular HSG(94)27. This guidance details the methods for investigating every homicide (and some suicides) by patients in current or recent contact with specialist mental health services. Part of the process to modernise HSG(94)27 includes a plan to build expertise within the National Health Service (NHS) in the technique of root cause analysis. This investigative process was developed in industry to identify causal or systems factors in serious adverse events.

scholarly journals Root cause analysis – what do we know?

2021 ◽  
Vol 95 (1/2) ◽  
pp. 87-93 ◽  
Author(s):  
Wendy Groot
Keyword(s):  
Adverse Events ◽  
Audit Quality ◽  
Opportunity To Learn ◽  
Root Cause Analysis ◽  
Policy Makers ◽  
Cause Analysis ◽  
Root Cause ◽  
Audit Firms ◽  
The Future ◽  
Blame Culture

Root cause analysis (RCA) provides audit firms, regulators, policy makers and practitioners the opportunity to learn from past adverse events and prevent them from reoccurring in the future, leading to better audit quality. Recently approved regulations (ISQM1) make RCA mandatory for certain adverse events, making it essential to learn how to properly conduct an RCA. Building on the findings and recommendations from the RCA literature from other industries where RCA practice is more established such as the aviation and healthcare industries, audit firms can implement an adequate and effective RCA process. Based on the RCA literature, I argue that audit firms would benefit from a systems-based approach and establishing a no-blame culture.

Multiple Systemic Contributors versus Root Cause

2016 ◽  
Vol 60 (1) ◽  
pp. 264-264 ◽  
Author(s):  
Katherine E. Walker ◽  
David D. Woods ◽  
Michael F. Rayo
Keyword(s):  
Adverse Events ◽  
Human Error ◽  
Space Station ◽  
Root Cause Analysis ◽  
Near Miss ◽  
Specific Sequence ◽  
Cause Analysis ◽  
Extravehicular Activity ◽  
Root Cause ◽  
Sequence Of Events

In 2013 NASA nearly drowned an astronaut during an Extravehicular Activity (EVA 23) on the International Space Station due to spacesuit water leakage. Indicators of trouble on the preceding EVA (22) were discounted. NASA carried out an investigation of the near miss event that is a sample of how root cause analysis is carried out in actual organizations (National Aeronautics and Space Administration, 2013). This paper contrasts the root cause analysis with a new analysis the authors carried out that captures how multiple systemic contributors combined to create the conditions that led up to the near miss. The new analysis illustrates the original finding from the late 1980s that accidents arise from multiple factors each necessary but only jointly sufficient (Reason, 1990; Woods, 1990; Cook, 2000; Woods, Dekker, Cook, Johannesen, & Sarter, 2010). Many of these contributors are system factors that have been present (latent) in the organization for some time prior to the specific sequence of events. In other words, the accidents arose from organizational or systemic factors (Reason, 1997). In contrast, the traditional root cause analysis focuses on the human roles closest to the adverse event and only raises systemic issues in terms of vague generalities that are difficult to address in systemic improvements (Dekker, 2014; Woods et al., 2010). The paper provides this contrast for two purposes. The first goal of this paper is to provide a concrete technique and diagram for identifying systemic contributors to adverse events (Systemic Contributors Analysis and Diagram or SCAD). The second goal is to highlight how the current practice of root cause analysis is unable to come to grips with systemic issues, misses the interactions between contributors, and misses emergent system properties. Using this systemic technique reveals that adverse events are very often due to production pressure at the blunt end, not human error at the sharp end of systems.

scholarly journals Considerations on immunization anxiety-related reactions in clusters

2014 ◽  
pp. 136-140 ◽  
Author(s):  
Ricardo Palacios
Keyword(s):  
Adverse Events ◽  
Systems Analysis ◽  
Stress Test ◽  
Vaccine Safety ◽  
Root Cause Analysis ◽  
Immunization Program ◽  
Cause Analysis ◽  
Root Cause ◽  
Psychogenic Illness ◽  
Related Reaction

A cluster of adverse events following immunization (AEFI) represents a stress test for an immunization program. The community can suspect on vaccine-related reaction leading to mistrust on the immunization program. An immunization anxiety-related reaction is one of the hypotheses to be tested and can be reasonably accepted when the vaccine-related and immunization error-related reactions are ruled out and no coincidental events can explain the cases. Immunization program approaches widely accepted to understand and respond to adverse events are root-cause analysis and systems analysis. Psychiatric cognitive frame will support the root-cause analysis assigning a causal relationship to individual temporary disorders of the affected vaccinees. Communication will focus on vaccine safety and absence of errors in the immunization program. Systems analysis addresses the whole context considering the fear spread as a systemic threat. Socio-psychological frame offers a broader opportunity to understand and respond to a specific community. Management is based on communication to change community belief in misperceptions of vaccine risks and support the idea of immunization as a causal factor, different from the vaccine. Communities can consider use of psychiatric labels, Mass Psychogenic Illness or Mass Hysteria, as an act of inconsiderateness. Labels like immunization anxiety-related reactions in clusters or collective immunization anxiety-related reactions are recommended to bridge the causal perception of the community with the result of the scientific investigation of the cases.

Sign in / Sign up

Export Citation Format

Share Document