When Do You Stop Your Root Cause Analysis Investigation as a Patient Safety Professional?

Using Root Cause Analysis to Reduce Risk to Our Patients

The number one priority for Patient Safety professionals is to reduce the chances of something bad happening to patients and staff. The fallout of serious incidents or events can be catastrophic. It can cause an organization to lose funding, incur heavy fines, layoff staff, impair or destroy culture, and even close its doors. Patient Safety professionals are risk managers. Their ability to identify and fix problems to reduce risk to patients is incredibly important. So, let’s do a quick-and-easy risk assessment of a patient safety root cause analysis process.

Our Patient Safety Event

To keep things simple, let us say we had an infectious control problem. A patient was isolated because they had MRSA, a life-threatening, highly resistant organism. Somehow, another patient on that floor also contracted MRSA, putting their life at risk.

Our Investigation

We investigate the incident and find out that a caregiver did not use the proper PPE when entering the isolation room to answer the call light. We know that it is policy to don the correct PPE when entering an isolation room.

From our quick investigation, we know that a caregiver disregarded a policy they were trained on. That led to another patient getting MRSA; another life put at risk. It also caused the hospital to deal with the cost and consequences of cross-contamination.

Who Did What Wrong?

Should our RCA investigation stop there? Do we know enough? If our normal RCA investigation process stopped here because we found out who did what wrong, our corrective actions would likely focus on that caregiver. We would get together and discuss what needs to happen to that caregiver. If the caregiver had problems in the past, we would probably recommend progressive discipline. If they had not had issues in the past, we would probably put them through training, again, and warn them to always use the correct PPE.

Or, the pressure may be on us to make a stronger example of this caregiver and terminate them. If this is all we know from our investigation, we may determine that even though discipline is hard, we did the right thing by holding someone accountable. Therefore, we have reduced the chances of this incident from happening again.

How Did This Happen?

Now let’s say, we didn’t stop there. Rather, we decided we need to know more about how this happened. We kept asking questions and the caregiver told us that they did not realize that the PPE had to be fully donned to answer a call light. The caregiver said they thought the mask was good enough since they were likely only asking what the patient needed. The patient asked for water, which the caregiver provided, and then left the room to answer another call light that was also flashing. Now we know how this incident happened as well as who did what wrong. At this point, our discussion would probably focus on how to ensure all caregivers know about the policy to wear full PPE when entering an isolation room for any reason. So, the team suggests a corrective action that requires adding wording to the PPE policy to make it crystal clear that full PPE is to be worn when whenever a caregiver enters an isolation room. We even created another corrective action that will ensure all staff is educated on the change and to reinforce the importance of following the policy. The team feels as though it has done everything possible to prevent this from happening again.

Why Did This Happen?

Now let’s say, we didn’t stop when we found out who did what wrong and how that happened. We continued asking questions and found out that the employee also didn’t locate the correct size of gown available and didn’t feel it was the right thing to do to ignore the call light for the amount of time it would take to find the proper PPE. Faced with this decision, the caregiver chose to take care of the patient instead of taking time to find the right gown. We decided to look at why the right-sized gown was not available and found out that we don’t have a standard to follow so our staff knows exactly what protective equipment needs to be immediately available for entering the isolation room and where that PPE needs to be stored for easy access.

Our conversation now turns away from looking at the caregiver, and we look at our systems. We create a corrective action that introduces a standard and provides clarity for staff. We stipulate which PPE and sizes need to be stocked and where it needs to be stored. After talking to our caregivers, we know the best place to store the PPE is just outside the isolation room instead of at the nurses’ station as we normally do.  We create a process to ensure each shift checks that the right PPE is available before each shift, using a checklist to be turned in for supervisor review. We also decide to audit this process daily for two weeks and then monthly. It becomes part of our QA reporting during our meetings.

The Power of Improving Systems Instead of Trying to Fix People

If we get to this point, we are more confident that we have reduced the risk of another incident. We used human performance factors to create corrective actions intended to improve our system so that it supports staff. We have made it easier for staff to follow important policies. Our staff saw that we investigated thoroughly and didn’t stop when we found out who did what wrong, nor did we make an example of their mistake. Instead, we improved the system to keep both the patient and the staff safe.  We reduced risk, leading us to our zero-harm goal while improving our culture.

Give Your Patient Safety Team the Training and Tools Necessary to Leverage Human Performance Factors

TapRooT® not only trains investigators to go through this process fully but also gives them tools built from human performance research and expertise. The TapRooT® RCA framework provides investigators with human performance-based questions that will help determine the root causes of problems. Eventually, the questions and answers will lead them to specific, fixable root causes. Then, the most important part, we will show them how to create effective corrective actions. Corrective actions that are based on human performance factors so they help people do their jobs. We will also teach how to ensure the corrective actions are implemented well and how to validate and verify they are working as intended. Top 3 Reasons Corrective Actions Fail & What to Do About It.

If you would like to know more about the TapRooT process for Patient Safety professionals and other staff who must manage risk, I can be reached at Marcus.miller@taproot.com.