Preventing wrong site, procedure, and patient events using a common cause analysis.

Area of Science:

• Healthcare Quality Improvement
• Patient Safety
• Medical Error Analysis

Background:

• The medical center reported 8 wrong-site, wrong-procedure, or wrong-patient events between April 2008 and January 2010.
• Sentinel events trigger a root cause analysis (RCA) within 45 days at this institution.

Purpose of the Study:

• To conduct a common cause analysis (CCA) on 8 wrong-site/procedure/patient events.
• To identify causal factors and trends contributing to these medical errors.
• To develop targeted interventions to prevent recurrence.

Main Methods:

• A common cause analysis (CCA) was performed on all 8 reported events.
• Failure modes were categorized, with a focus on Rules, Policies, and Procedures, and Human Factors (Scheduling and Fatigue).
• A multidisciplinary team confirmed findings and developed corrective processes.

Main Results:

• The CCA identified 22 failure modes in Rules, Policies, and Procedures.
• 17 failure modes were identified within Human Factors: Scheduling and Fatigue.
• No wrong-site, wrong-procedure, or wrong-patient events have occurred in the year following intervention.

Conclusions:

• Addressing systemic issues in rules, policies, procedures, scheduling, and fatigue is critical for preventing wrong-site events.
• Multidisciplinary collaboration is effective in identifying and mitigating patient safety risks.
• Process improvements based on CCA findings significantly enhanced patient safety and eliminated specific medical errors.