The Veterans Affairs root cause analysis system in action

Area of Science:

• Healthcare Quality Improvement
• Patient Safety Research
• Systems Engineering in Medicine

Background:

• The Department of Veterans Affairs (VA) established the National Center for Patient Safety (NCPS) in 1998 to lead patient safety initiatives.
• VA facilities utilize front-line expertise and root cause analysis (RCA) for adverse events and close calls.
• Facility patient safety managers use the Safety Assessment Code (SAC) to prioritize event severity and frequency.

Purpose of the Study:

• To evaluate the shift in adverse event analysis from a focused review (FR) system to a new RCA system implemented in 2000.
• To compare the effectiveness of the RCA process with the previous FR system in identifying actionable root causes.
• To demonstrate the application and impact of the RCA system through case examples.

Main Methods:

• A before-and-after study comparing the FR system with the new RCA system.
• Analysis of adverse events and close calls using a human factors engineering approach within the RCA process.
• Illustrative case studies of RCA application in magnetic resonance imaging (MRI) room hazards and cardiac pacemaker malfunctions.

Main Results:

• The RCA process has shifted analyses toward identifying system vulnerabilities rather than solely focusing on human errors.
• The RCA system facilitates a more in-depth examination of less actionable root causes.
• Case examples demonstrate that thorough RCA can lead to broadly applicable, high-impact safety actions.

Conclusions:

• The NCPS actively monitors RCA quality and completeness through immediate review and feedback.
• The RCA system promotes a human factors engineering approach to patient safety.
• Further investigation is needed to determine the effectiveness of RCA-driven actions in preventing future adverse events.