Root cause analysis in infusion nursing: applying quality improvement tools for adverse events

Area of Science:

• Healthcare Quality Improvement
• Patient Safety Science
• Clinical Risk Management

Background:

• Root cause analysis (RCA) adoption in healthcare originated in the Veteran's Administration system.
• RCA became a requirement for accreditation in Joint Commission-accredited organizations.
• Effective RCA implementation requires understanding patient safety principles and team collaboration.

Purpose of the Study:

• To describe optimal root cause analysis (RCA) techniques for healthcare.
• To provide a practical example of RCA application for a common adverse event.

Main Methods:

• Literature review of published RCA techniques.
• Incorporation of expert opinion on RCA best practices.
• Development of a sample RCA for catheter-associated bloodstream infection.

Main Results:

• Optimal RCA techniques involve understanding patient safety, team assembly, and action item completion.
• A sample RCA demonstrates the application of these techniques to a specific clinical scenario.

Conclusions:

• Root cause analysis is a critical tool for improving healthcare quality and patient safety.
• Systematic application of RCA principles can effectively address adverse events.
• The described techniques and sample case provide a framework for healthcare organizations to implement RCA.