Apparent Cause Analysis: A Safety Tool.

Area of Science:

• Healthcare Safety
• Risk Management
• Patient Safety

Background:

• Established root cause analysis protocols exist for serious events, but guidance for apparent cause analysis (ACA) in healthcare is limited.
• Precursor and near-miss safety events require effective investigation methods to prevent escalation.
• A need exists for efficient and structured approaches to analyze less severe safety events in healthcare settings.

Purpose of the Study:

• To develop and implement a novel facilitated ACA approach to improve safety culture.
• To provide a clear and resource-efficient method for addressing precursor and near-miss safety events.
• To establish a structured process for organizational cause analysis in a pediatric hospital setting.

Main Methods:

• A facilitated ACA model, defined as a limited investigation of low-harm events, was developed with an operational algorithm and structured process.
• The model was implemented at a tertiary-care, urban pediatric hospital.
• Process measures, including time to ACA launch and resources utilized, were tracked.

Main Results:

• Sixty-four facilitated ACAs were completed, with 83% of events identified using the implemented algorithm.
• The median time from event reporting to ACA launch was 3 days (IQR 2-6 days).
• Patient safety consultants averaged 5 hours per facilitated ACA, involving a median of 3 disciplines.

Conclusions:

• The facilitated ACA model provides a structured and efficient approach to investigate safety events with minimal harm.
• Key strengths include selecting the right event, team, analysis, and action plans for effective outcomes.
• This novel approach has the potential to support organizational cause analysis and enhance safety culture, leading to more reliable processes.