Bringing Root Cause Analysis up to Speed: The Impact of Increasing the Volume and Rapidity of RCAs

1University of California, San Francisco, San Francisco, CA
2University of California, San Francisco, San Francisco, CA
3University of California, San Francisco, San Francisco, CA
4University of California, San Francisco, San Francisco, CA

Meeting: Hospital Medicine 2008, April 3-5, San Diego, Calif.

Abstract number: 87

Background:

In 1999, the Institute of Medicine's To Err is Human reported that nearly 100,000 people die from medical errors each year in the United States. One proposed solution was detailed root cause analyses of errors, emphasizing system flaws rather than human failings (root cause analyses). However, there was little guidance on which cases merited RCAs, how rapidly to perform then, or what actions should result. In an effort to rationalize the RCA process and public error reporting, the National Quality Forum (NQF) created a list of 27 “never events,” a consensus‐generated list focusing on errors deemed preventable, identifiable, and measurable. On July 1, 2007, California joined more than 20 other states by requiring that hospitals report NQF never events, but the state added a new element of urgency: a requirement to report within 5 days of the event and possible on‐site inspections by the Department of Health Services within 48 hours of reporting.

Purpose:

In response to the new California reporting legislation, the UCSF Medical Center created the Clinical Event Oversight Committee (CEOC), tasked with performing prompt RCAs of medical errors and enacting the recommended changes. We evaluated the activities and output of the CEOC during its first year.

Description:

The CEOC performs RCAs in a blame‐free environment, focusing on systemic factors leading to error‐ and risk‐reduction strategies to decrease future errors. A standing weekly 2‐hour meeting was established as a means to rapidly develop a clear understanding of events prior to mandatory reporting and site visits. Standing committee members include executive medical center leadership, experts in patient safety and quality, and key medical staff supervisors. Participants involved in the case present the facts and circumstances of the event. The group uses standardized RCA tools to identify system issues and areas for intervention. In its first year, the CEOC has resulted in a 30% decrease in the average number of days from event to RCA and a 56% increase in the number of events analyzed. Having a rigorous RCA structure in place has also allowed us to identify trends, with some themes becoming clear only with experience.

Conclusions:

The creation of the CEOC has allowed our institution to quickly and effectively respond to adverse events, thereby advancing a culture of patient safety. Going beyond minimum requirements, we have transformed our RCA process into an invaluable tool to identify system flaws and develop strategies to correct them.

Author Disclosure:

N. Allaudeen, none; R. Wachter, none; B. Ide, none; K. Radics, none.

To cite this abstract:

Allaudeen N, Wachter R, Ide B, Radics K. Bringing Root Cause Analysis up to Speed: The Impact of Increasing the Volume and Rapidity of RCAs. Abstract published at Hospital Medicine 2008, April 3-5, San Diego, Calif. Abstract 87. Journal of Hospital Medicine. 2008; 3 (suppl 1). https://www.shmabstracts.com/abstract/bringing-root-cause-analysis-up-to-speed-the-impact-of-increasing-the-volume-and-rapidity-of-rcas/. Accessed September 22, 2019.

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