ABSTRACT
Introduction
A full root cause analysis (RCA) such as that required following a sentinel event is time-consuming, labor-intensive, and expensive. This quality improvement project used a similar but abbreviated process (mini-RCA and action; mini-RCA2) in response to medication errors that caused less serious harm.
Methods
In 2018, all medication errors that caused harm due to system failures but were not sentinel events were investigated by mini-RCA2. The incidence of similar medication errors reported in the year before and in the year after the introduction of mini-RCA2 was compared to determine the impact of this intervention. Similar events were identified by searching the safety reporting system database for reported medication errors by drug name (e.g., Humate® P) and/or event type (e.g., prescribing error—omission of a patient's home medications on admission to hospital). The time and labor costs of this intervention were estimated.
Results
Seven medication errors were investigated by mini-RCA2. More than 48 members of staff from 11 clinical and nonclinical departments contributed to the identification of 39 system failures and made 42 recommendations, of which 22 (52%) were implemented. This reduced the recurrence of reports of similar events from 35 (0.57%) to 21 (0.36%). Although this 0.21% absolute decrease did not achieve statistical significance, recurrence of similar harm events was reduced from 7 (0.11%) to 0 (p = 0.016). Benefits were greatest when the mini-RCA2 recommendations were fully implemented. This reduced the recurrence of similar events from 9 (0.21%) to 0 (p = 0.007). A total of 251 hours (mean ± SD, 35.9 ± 16.6 hours) were required for this intervention. The associated labor cost was Saudi Arabia Riyal (SAR) 34,181 (US $8256; mean SAR ± SD, 4883 ± 1302 [mean US $ ± SD, $2102 ± $561]).
Conclusion
The use of mini-RCA2 to review medication errors provided a structured process to manage reported events, monitor the implementation of recommendations, and assess the effectiveness of implemented actions. The use of this rapid process to investigate errors that cause harm but are not sentinel events reduced recurrence of similar medication errors. Although the time and cost required for this intervention is not insignificant, the cumulative benefit to patients, healthcare professionals, and the organization are greater.
Root cause analysis applied to the investigation of serious untoward incidents in mental health services
