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System-wide learning from root cause analysis: a report from the New South Wales Root Cause Analysis Review
Jonny Taitz1, Kelvin Genn, Vanessa Brooks
1Clinical Excellence Commission, Martin Place, Sydney, New South Wales, Australia. jonny.taitz@sesiahs.health.nsw.gov.au
Quality & Safety in Health Care
|July 31, 2010
Summary
Root Cause Analysis (RCA) in New South Wales (NSW) involves extensive time investment. Aggregating RCA data helps identify system factors, but further review is needed to ensure patient safety improvements.
Area of Science:
- Healthcare Quality Improvement
- Patient Safety Research
- Clinical Risk Management
Background:
- Preventable medical errors are prevalent in healthcare settings.
- Root Cause Analysis (RCA) is a critical tool for investigating adverse events.
- The New South Wales (NSW) RCA Review Committee was established to analyze RCA data.
Purpose of the Study:
- To highlight the work of the NSW RCA Review Committee.
- To discuss the benefits of classifying, aggregating, and disseminating RCA data.
- To identify emerging themes and factors contributing to adverse events.
Main Methods:
- Review of 445 Root Cause Analyses (RCAs) over 14 months.
- Development of a taxonomy for assessing RCAs based on health and aviation standards.
- Analysis of underlying human, patient, and system factors.
Main Results:
- Identified emerging themes and aggregated data on contributing factors.
- 41 RCAs were related to errors in acute coronary syndrome management.
- A taxonomy was developed and applied to assess RCAs.
Conclusions:
- Aggregated RCA data aids in understanding contributing factors to adverse events.
- The effectiveness of RCA recommendations requires further investigation.
- Concerns exist regarding staff empowerment to report systemic issues.
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