Does Root Cause Analysis improves patient safety?
This editorial letter discusses the important subject of root cause analysis (RCA) and how it might increase patient safety. To investigate adverse incidents and determine underlying causes and contributing factors, the letter highlights the importance of RCA as a methodical and comprehensive technique. Important information about the use of RCA in health care, its steps, and the possible effects on patient safety can be found in the references included in this letter.
RCA identifies system failure reasons. It offers the information required to resolve failures and helps clinical risk managers and clinical staff to address major adverse event inquiries. Doing so enhances patient safety and also emphasizes the importance of improving the safety culture in healthcare facilities. By exploring RCA in more detail and outlining its measures to improve patient safety, the letter seeks to improve healthcare quality and patient safety.
Full Article
Dear Editor,
We are writing to address the critical topic of root cause analysis and its significance in enhancing patient safety. Root cause analysis (RCA) is a systematic and comprehensive examination of patient safety incidents in order to identify basic causes and elements that contribute to them, and the ultimate goal is to extract valuable insights to make quality improvements.(1)
The RCA approach encompasses several key components that are vital for understanding the fundamental reasons for patient safety accidents and applying impactful enhancements. The initial stage of RCA involves clearly defining the problem at hand and assembling a multidisciplinary team to carry out the analysis. The composition of this team should comprise people with varied perspectives and expertise to guarantee a thorough examination.
The subsequent stage entails the collection of data and evidence of the incident, encompassing medical records, witness accounts, and other pertinent documents. After gathering the data, the team can then analyze and determine the causal elements that led to the occurrence of adverse events. To complete this step, it is necessary to conduct a comprehensive assessment of the chronological order of events leading to the incident, as well as an evaluation of the systemic and human elements that played a role.(2)
RCA’s recognition as a notable approach for examining critical incidents in healthcare systems globally emphasizes its importance in the healthcare industry.(3) Research has demonstrated that the implementation of RCA results in an in-depth review of errors, which in turn improves patient safety.(4) The efficacy and productivity of RCA in the realm of patient safety have been extensively documented and have been utilized in many medical scenarios, encompassing otorhinolaryngology, surgery, and general healthcare.(5)
In summary, root cause analysis is an essential tool in the reporting of adverse events in healthcare organizations. It allows for the discovery of underlying systemic problems, contributing causes, and the creation of focused actions to improve patient safety.
Funding: None declared.
Conflict of Interest: The authors declare that they have no competing interests.
References
- Jhugursing M, Dimmock V, Mulchandani H. Error and root cause analysis. Bja Education 2017 Oct 1;17(10):323-33. https://doi.org/10.1093/bjaed/mkx019
Driesen BE, Baartmans M, Merten H, Otten R, Walker C, Nanayakkara PW, Wagner C. Root cause analysis using the prevention and recovery information system for monitoring and analysis method in healthcare facilities: a systematic literature review. Journal of Patient Safety 2022 Jun;18(4):342. https://doi.org/10.1097/pts.0000000000000925
Peerally MF, Carr S, Waring J, Dixon-Woods M. The problem with root cause analysis. BMJ Qual Saf 2017 May;26(5):417- 22. https://doi.org/10.1136/bmjqs-2016-005511
Zohourian P, Amini AS, Davooodi R, Shojaeian M. Analysis of the Root Causes of an undesirable incident in a hospital in Mashhad, 2013. Bangladesh Journal of Medical Science 2016;15(4):637. https://doi.org/10.3329/bjms.v15i4.30721
Wu AW, Lipshutz AK, Pronovost PJ. Effectiveness and efficiency of root cause analysis in medicine. Jama 2008 Feb 13;299(6):685-7. https://doi.org/10.1001/jama.299.6.685.
