scholarly journals Root-Cause Analysis of Persistently High Maternal Mortality in a Rural District of Indonesia: Role of Clinical Care Quality and Health Services Organizational Factors

2018 ◽  
Vol 2018 ◽  
pp. 1-11 ◽  
Author(s):  
Mohammad Afzal Mahmood ◽  
Ismi Mufidah ◽  
Steven Scroggs ◽  
Amna Rehana Siddiqui ◽  
Hafsa Raheel ◽  
...  
Keyword(s):  
Quality Of Care ◽  
Maternal Mortality ◽  
Clinical Care ◽  
Organizational Factors ◽  
Root Cause Analysis ◽  
Care Quality ◽  
Cause Analysis ◽  
Root Cause ◽  
Essential Services

Background. Despite significant reduction in maternal mortality, there are still many regions in the world that suffer from high mortality. District Kutai Kartanegara, Indonesia, is one such region where consistently high maternal mortality was observed despite high rate of delivery by skilled birth attendants. Method. Thirty maternal deaths were reviewed using verbal autopsy interviews, terminal event reporting, medical records’ review, and Death Audit Committee reports, using a comprehensive root-cause analysis framework including Risk Identification, Signal Services, Emergency Obstetrics Care Evaluation, Quality, and 3 Delays. Findings. The root causes were found in poor quality of care, which caused hospital to be unprepared to manage deteriorating patients. In hospital, poor implementation of standard operating procedures was rooted in inadequate skills, lack of forward planning, ineffective communication, and unavailability of essential services. In primary care, root causes included inadequate risk management, referrals to facilities where needed services are not available, and lack of coordination between primary healthcare and hospitals. Conclusion. There is an urgent need for a shift in focus to quality of care through knowledge, skills, and support for consistent application of protocols, making essential services available, effective risk assessment and management, and facilitating timely referrals to facilities that are adequately equipped.

scholarly journals Teaching Root Cause Analysis Using Simulation: Curriculum and Outcomes

2019 ◽  
Vol 6 ◽  
pp. 238212051989427
Author(s):  
Maya Aboumrad ◽  
Julia Neily ◽  
Bradley V Watts
Keyword(s):  
Experiential Learning ◽  
Health Care Quality ◽  
Chief Resident ◽  
Role Playing ◽  
Root Cause Analysis ◽  
Care Quality ◽  
Learning Objectives ◽  
Quality And Safety ◽  
Cause Analysis ◽  
Root Cause

Background: Clinicians are key drivers for improving health care quality and safety. However, some may lack experience in quality improvement and patient safety (QI/PS) methodologies, including root cause analysis (RCA). Objective: The Department of Veterans Affairs (VA) sought to develop a simulation approach to teach clinicians from the VA’s Chief Resident in Quality and Safety program about RCA. We report the use of experiential learning to teach RCA, and clinicians’ preparedness to conduct and teach RCA post-training. We provide curriculum details and materials to be adapted for widespread use. Methods: The course was designed to meet the learning objectives through simulation. We developed course materials, including presentations, a role-playing case, and an elaborate RCA case. Learning objectives included (1) basic structure of RCA, (2) process flow diagramming, (3) collecting information for RCA, (4) cause and effect diagramming, and (5) identifying actions and outcomes. We administered a voluntary, web-based survey in November 2016 to participants (N = 114) post-training to assess their competency with RCA. Results: A total of 93 individuals completed the survey of the 114 invited to participate, culminating an 82% response rate. Nearly all respondents (99%, N = 92) reported feeling at least moderately to extremely prepared to conduct and teach RCA post-training. Most respondents reported feeling very to extremely prepared to conduct and teach RCA (77%, N = 72). Conclusions: Experiential learning involving simulations may be effective to improve clinicians’ competency in QI/PS practices, including RCA. Further research is warranted to understand how the training affects clinicians’ capacity to participate in real RCA teams post-training, as well as applicability to other disciplines and interdisciplinary teams.

A root-cause analysis of Maternal Mortality in a tertiary care hospital

2012 ◽  
Vol 2 (7) ◽  
pp. 383-384
Author(s):  
Dr. Samipa J. Shah ◽  
◽  
Dr. Akshay Shah ◽  
Dr. Punit B . Vasa ◽  
Dr. Yamini Trivedi
Keyword(s):  
Maternal Mortality ◽  
Tertiary Care Hospital ◽  
Tertiary Care ◽  
Root Cause Analysis ◽  
Care Hospital ◽  
Cause Analysis ◽  
Root Cause

Root cause analysis in the NHS: time for change?

2020 ◽  
Vol 81 (4) ◽  
pp. 1-4
Author(s):  
Shyam Kumar ◽  
Roger Kline ◽  
Tracy Boylin
Keyword(s):  
Human Factors ◽  
Group Dynamics ◽  
Task Complexity ◽  
General Medical Council ◽  
Root Cause Analysis ◽  
Care Quality ◽  
Medical Council ◽  
Human Factors Engineering ◽  
Cause Analysis ◽  
Root Cause

Root cause analyses were intended to search for system vulnerabilities rather than individual errors, using a human factors engineering approach. In practice, root cause analyses done in the NHS may generally fail to identify components where there are organisational failures, as there may be an inherent desire to protect institutional reputation. A human factors approach to root cause analysis looks at system vulnerabilities, considering the entirety of the environment in which an individual works and taking into account factors such as the physical environment and individual mental characteristics. Other human factors include group dynamics, task complexity and concurrent tasks. It is time that the growing evidence of the potential shortcomings of root cause analysis, especially as frequently applied within the NHS, is heeded. At present, rather than assisting learning it may be an impediment to patient safety. The authors propose that root cause analyses should be performed by a group of people who are not managing the service. External organisations such as the General Medical Council, Nursing and Midwifery Council, Care Quality Commission and Practitioner Performance Assessment are heavily reliant on this tool when concerns are raised. If the flaws in root cause analysis can be eliminated, drawing on the available evidence, cases such as those of Dr Hadiza Bawa-Garba and Mr David Sellu might be avoided.

scholarly journals Root-Cause Analysis of Maternal Mortality in Fars Province, Southern Iran 2014: Negligence Is the Prime Suspect

2020 ◽  
Author(s):  
Alireza Mirahmadizadeh ◽  
Ali Semati ◽  
Babak Eshrati ◽  
Fariba Moradi ◽  
Nasrin Asadi
Keyword(s):  
Health Care ◽  
Sensitivity Analysis ◽  
Maternal Mortality ◽  
Surveillance System ◽  
Root Cause Analysis ◽  
Careful Examination ◽  
Fars Province ◽  
Maternal Deaths ◽  
Cause Analysis ◽  
Root Cause

Objective: we aimed to carry out an applied methodological tool, using Root-Cause Analysis (RCA), to determine the main causes of maternal mortality in Fars province, south of Iran, in 2014. Materials and methods: This is a case-series study and was conducted based on a careful examination of records and verbal autopsy with the family of the deceased person and their medical care team. Using RCA, quantitative dynamic modeling was done to display the overall impacts of different causes on maternal mortality. Finally, sensitivity analysis was done to determine the magnitude of contribution of each root-cause of maternal mortality. Results: Totally, all 10 maternal deaths with Maternal Mortality Rate (MMR) of 13.4 per 100.000 births, were recorded in the maternal surveillance system during 2014. The RCA results revealed that the root-causes of maternal mortality were ignorance and negligence (50%), delay in diagnosis (30%), delay in service provision in the first 24 hours after delivery (10%), and undesirable health care (10%). The results of sensitivity analysis in different scenarios revealed that medical negligence had the highest contribution to maternal mortality. Conclusion: Although maternal surveillance system stated some causes such as hemorrhage to be responsible for maternal deaths, the RCA showed that root-causes such as medical neglects had a fundamental role. Therefore, maternal mortality can be prevented by reforming the health care system and training all service providers, especially for high-risk mothers.  

scholarly journals Root Cause Analysis, Failures and Effects in pediatric total quality management: a scoping review

2021 ◽  
Vol 74 (6) ◽  
Author(s):  
Luciana Andrade de Lima ◽  
Louise Constancia de Melo Alves Silva ◽  
Joyce Karolayne dos Santos Dantas ◽  
Maria Solange Moreira de Lima ◽  
Daniele Vieira Dantas ◽  
...  
Keyword(s):  
Failure Mode ◽  
Scoping Review ◽  
Root Cause Analysis ◽  
Total Quality ◽  
Post Intervention ◽  
Effect Analysis ◽  
Cause Analysis ◽  
Root Cause ◽  
Scoping Reviews

ABSTRACT Objectives: to analyze the applicability of Root Cause Analysis and Failure Mode and Effect Analysis tools, aiming to improve care in pediatric units. Methods: this is a scoping review carried out according to the Joanna Briggs Institute guidelines, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes extension for Scoping Reviews. Search took place in May 2018 on 15 data sources. Results: search totaled 8,254 studies. After using the relevant inclusion and exclusion criteria, 15 articles were included in the review. Of these, nine were published between 2013 and 2018, 12 used Failure Mode and Effect Analysis and 11 carried out interventions to improve the quality of the processes addressed, showing good post-intervention results. Final Considerations: the application of the tools indicated significant changes and improvements in the services that implemented them, proving to be satisfactory for detecting opportunities for improvement, employing specific methodologies for harm reduction in pediatrics.

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