Volume 30, Issue 107 (August 2017)                   IJN 2017, 30(107): 53-61 | Back to browse issues page

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Toghian Chaharsoughi N, Emadi F. Application Root Cause Analysis Technique in Investigating the Causes of a Fatal Sentinel Event: Case Report. IJN 2017; 30 (107) :53-61
URL: http://ijn.iums.ac.ir/article-1-2490-en.html
1- Instructor, Nursing & Midwifery Sciences Development Research Center, Najafabad Branch, Islamic Azad University, Najafabad, Iran. (*Corresponding Author) Tel: 09133285851 Email:toghiann@gmail.com
2- BS in Health Management, Health Quality Improvement Department, Ayatollah Kashani Hospital, Isfahan,Iran
Abstract:   (5434 Views)
Background & Aim: Medical errors are among the most challenging threats to health systems in all countries. Thus, it is essential to take actions to reduce the risk of sentinel events reoccurrence. Root cause analysis is one of the risk management models, used for retrospective analysis of the root cause or causes of errors and weaknesses in a system or its related processes systematically. This study aimed to analyze the root causes of a sentinel event led to death in one of the hospitals in Isfahan in 2015.
Materials & Methods: This is a case report study that analyzes root causes of medical errors.  The study was consisted of seven steps including: determining an event that must be analyzed, organizing a team to run it, gathering relevant data, identifying problems, searching for the causes of the incident, providing solutions, implementing solutions, and assessing and writing research report that lasted for 9 months.
Results: The results showed that the first reason was lack of policy and protocol, developed for how to triage patients from one service to other services in the hospital, which caused problems in managing and assuming the responsibility of the patient's administration. The second fundamental problem was the patient’s examination by different specialists regardless of the status and progression of the clinical symptoms of the patient that caused loss of key information in the process of the patient clinical symptoms.
Conclusion: Due to the benefits of this technique in identifying the root causes of errors, it can be used to prevent similar errors, eliminate organization defects, correct processes in the organization, and improve patient safety.
Full-Text [PDF 653 kb]   (2464 Downloads)    
Type of Study: Research | Subject: nursing
Received: 2017/05/16 | Accepted: 2017/08/22 | Published: 2017/08/22

1. Bowie P, Skinner J, de Wet C. Training health care professionals in root cause analysis: a cross-sectional study of post-training experiences, benefits and attitudes. BMC Health Serv Res. 2013; 13(1):50. [DOI:10.1186/1472-6963-13-50] [PMID] [PMCID]
2. Garrouste-Orgeas M, Flaatten H, Moreno R. Understanding medical errors and adverse events in ICU patients. Intensive Care Med. 2016; 42(1):107-9. [DOI:10.1007/s00134-015-3968-x] [PMID]
3. Yarmohammadian MH, Rezaee F, Varesi M, Atighechian G. [Risk Management in the Department of Surgery and Intensive Care], Isfahan University of Medical Sciences and Health Services, Isfahan province. 2014. 136-48.
4. Braithwaite J, Westbrook M, Travaglia J. Attitudes toward the large-scale implementation of an incident reporting system. Int J Qual Health Care. 2008; 20(3):184-91. [DOI:10.1093/intqhc/mzn004] [PMID]
5. Charles R, Hood B, Derosier JM, Gosbee JW, Li Y, Caird MS, et al. How to perform a root cause analysis for workup and future prevention of medical errors: a review. Patient Saf Surg. 2016; 10(20): 1-5. [DOI:10.1186/s13037-016-0107-8]
6. Beigi M, Bahreini S, Valiani M, Rahimi M, Danesh-Shahraki A. [Investigation of the causes of maternal mortality using root cause analysis in Isfahan, Iran in 2013-2014]. Iran J Nurs Midwifery Res. 2015;20(3):315-21. [PMID] [PMCID]
7. BCOP G, Pavlik R, Jason J, Elena M. Development of an Inter-professional Root Cause Analysis Workshop within a Required Medication Safety Course. 2016.
8. Khorsandi M, Skouras C, Beatson K, Alijani A. Quality review of an adverse incident reporting system and root cause analysis of serious adverse surgical incidents in a teaching hospital of Scotland. Patient Saf Surg. 2012;6(1):21. [DOI:10.1186/1754-9493-6-21] [PMID] [PMCID]
9. Johna S, Tang T, Saidy M. Patient safety in surgical residency: root cause analysis and the surgical morbidity and mortality conference—case series from clinical practice. The Permanente Journal. 2012;16(1):67-9. [DOI:10.7812/TPP/11-097] [PMID] [PMCID]
10. Wu AW, Lipshutz AK, Pronovost PJ. Effectiveness and efficiency of root cause analysis in medicine. JAMA. 2008;299(6):685-7. [DOI:10.1001/jama.299.6.685] [PMID]
11. James JT. A new, evidence-based estimate of patient harms associated with hospital care. Journal of patient safety. 2013;9(3):122-8. [DOI:10.1097/PTS.0b013e3182948a69] [PMID]
12. Peerally MF, Carr S, Waring J, Dixon-Woods M. The problem with root cause analysis. BMJ Qual Saf. 2017;26(5):417-22. [PMID]
13. Nicolini D, Waring J, Mengis J. Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the gap. Soc Sci Med. 2011;73(2):217-25. [DOI:10.1016/j.socscimed.2011.05.010] [PMID]
14. Mahto D, Kumar A. Application of root cause analysis in improvement of product quality and productivity. Journal of Industrial Engineering and Management. 2008;1(2):16-53. [DOI:10.3926/jiem.2008.v1n2.p16-53]
15. Davoodi R, Takbiri A, Soltani FA, Rahmani S, Hoseini T, Sabouri G, et al. [Root Cause Analysis of an Adverse Event in a Hospital in Mashhad], 2012: CASE REPORT. 2013;16(2):153-9.
16. Corwin GS, Mills PD, Shanawani H, Hemphill RR. Root Cause Analysis of ICU Adverse Events in the Veterans Health Administration. The Joint Commission Journal on Quality and Patient Safety. 2017. [DOI:10.1016/j.jcjq.2017.04.009] [PMID]
17. Kellogg KM, Hettinger Z, Shah M, Wears RL, Sellers CR, Squires M, et al. Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? BMJ Qual Saf. 2017:bmjqs-2016-005991.
18. Adibi H, Najafpour Z, Jafari MR, Saeedi M. [Medical Adverse Events: Root Cause Analysis of 16 Reports From a Teaching Hospital]. Payesh. 2016;15(6): 629-37.
19. Sauer BC, Hepler CD. Application of system-level root cause analysis for drug quality and safety problems: A case study. Research in social and administrative pharmacy. 2013;9(1):49-59. [DOI:10.1016/j.sapharm.2012.02.005] [PMID]
20. Giardina TD, King BJ, Ignaczak AP, Paull DE, Hoeksema L, Mills PD, et al. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. Health Aff (Millwood). 2013;32(8):1368-75. [DOI:10.1377/hlthaff.2013.0130] [PMID] [PMCID]
21. Van Vliet V. Root Cause Analysis (RCA). January 4 2014: Available from: https://www.toolshero.com/problem-solving/root-cause-analysis-rca

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