Team experiences of the root cause analysis process after a sentinel event: a qualitative case study

Area of Science:

• Healthcare quality improvement
• Patient safety research
• Medical error analysis

Background:

• Root cause analysis (RCA) is a structured method for identifying causes of medical errors.
• This study investigates a Norwegian RCA team's experience and adherence to the national RCA method following a sentinel event.

Purpose of the Study:

• To explore the experiences of an RCA team during a complex case.
• To assess compliance with the Norwegian RCA method in practice.

Main Methods:

• A case study approach was employed to deeply analyze a specific sentinel event.
• Research questions focused on the RCA team's process experience and method compliance.

Main Results:

• Challenges arose from the hospital's management system and external factors like police involvement.
• The RCA team faced intrapersonal difficulties, including maintaining neutrality, role conflicts, and resource constraints.
• Adherence to RCA guidelines was tested by case complexities and team dynamics.

Conclusions:

• Findings offer insights into inter-professional RCA teamwork's impact on healthcare organizations.
• Results can guide the development, implementation, and education of RCA processes to improve patient safety.
• Understanding team experiences is crucial for optimizing RCA interventions and enhancing staff collaboration.