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Improving Root Cause Analysis of Patient Safety Events in Radiology.

Ashley S Rosier¹, Laura C Tibor¹, Mara A Turner¹

¹From the William J. von Liebig Center for Transplantation and Clinical Regeneration (A.S.R.) and Departments of Radiology (C.J.P., A.N.K.), Radiation Oncology (L.C.T.), and Quality Management Services (M.A.T.), Mayo Clinic, 200 First St SW, Rochester, MN 55905.

Radiographics : a Review Publication of the Radiological Society of North America, Inc

|September 2, 2020

Summary

Improving patient safety events requires effective root cause analysis (RCA) meetings. A radiology department enhanced its RCA process, boosting participant satisfaction and creating a more robust patient safety program.

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Area of Science:

Healthcare Quality Improvement
Patient Safety Research
Radiology Department Operations

Background:

Patient safety events necessitate thorough root cause analysis (RCA).
Feedback indicated dissatisfaction with the existing RCA process in a radiology department.
Systemic barriers often exist between optimal processes and actual practice.

Purpose of the Study:

To analyze the root causes of dissatisfaction with the RCA process.
To implement a structured improvement framework to enhance the RCA process.
To increase participant and facilitator satisfaction with RCA meetings.

Main Methods:

Utilized a structured process improvement framework.
Employed post-RCA surveys to measure satisfaction scores.
Applied methodologies to analyze and improve the RCA process.

Main Results:

Successfully increased participant and facilitator satisfaction levels with RCA meetings.
Achieved sustained improvements in satisfaction scores.
Developed a more robust, continuously improving patient safety program.

Conclusions:

Structured process improvement is effective for enhancing healthcare quality programs.
Measuring and improving difficult processes, like satisfaction, is achievable.
Enhanced RCA processes contribute to a stronger patient safety culture, aiding in event reporting and prevention.