Conducting an Infection Associated Root Cause Analysis

John R. Rosing, MHA, FACHEVice President and Principal

Patton Healthcare ConsultingMay 3, 2012

Sentinel Event Defined

• A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.

• Such events are called “sentinel” because they signal the need for immediate investigation and response.

• The term “sentinel event” and “medical error” are not synonymous; not all sentinel events occur because of an error, and not all error result in sentinel events.

Resulting in death or permanent loss of function

Surveillance, Prevention, and Control of Infection Sterilization/contamination, universal precautions

Identifying HAI Sentinel Events

• Regularly identify all deaths• Compare this list against the HAI data base to

look for overlap• Collaborate with ICC Chair or epidemiologist

to determine if death or disability was “unanticipated”

• Compare with expected mortality rates for various types of infections

What is a Root Cause Analysis?

• A credible process for identifying the basic or causal factors that underlie variation in performance.

• This process should be used to identify risk that led to a sentinel event.

• Use a RCA framework to drill down to root cause; complete within 45 days

How to Conduct a RCA

1. Organize a team, set ground rules, meeting dates, focus on process – not laying blame. Be sensitive to fears.

– Respected leader, staff close to the event, staff far from the event, and a RCA-experienced facilitator.

2. Define the Problem, what happened - not why, accurate and succinct.

How to Conduct a RCA

3. Study the problem, witness statements, observations, physical evidence, documentation evidence.

4. Determine what happened, flowchart the actual vs. ideal sequence of events, flowchart the steps in a policy/ procedure and compare the gaps, create a timeline of events.

How to Conduct a RCA

5. Why did the event occur? Which processes were involved? What are the steps in the process as designed? Which steps may have contributed to the event?

– Continue asking “Why” – What is currently done to prevent failure at this

step? Was it done? If not, why not?

How to Conduct a RCA

6. Identify other contributing factors, using the fishbone diagram technique.

7. Measure, collect and assess data.– Is this a one time event or a trend?– Measure process or steps in the process.– Assess effectiveness of improvements.– Measurements should be rate-based.

How to Conduct a RCA

8. Design and implement interim changes, fix low hanging fruit, create a timeline of fixes that remain, gain commitment and resources to complete these fixes.

9. Identify the root causes– Usually framed as the Proximate and Underlying

causes.

How to Conduct a RCA

10. Prune the list of Root Causes– Would the problem have occurred if cause #1

had not been present?– Will the problem recur due to same causal factor

if cause #1 is corrected or eliminated?– Will correction or elimination of cause #1 lead to

similar events?• Yes = contributing cause, No = root cause

How to Conduct a RCA 11. Confirm the Root Cause, study the

literature, look for other risk reduction strategies. Don’t blame the individual.

12.Error prevention strategies, hard-wire, make the right thing to do the easiest thing to do, eliminate the error, make fool-proof – recognizing that nothing is outside the capability of a

sufficiently talented fool!

Now try this!Learn From a Defect Tool

• An easier-to-master RCA Tool developed at Johns Hopkins Medical Center– (Journal of Quality and Safety, 2006;32(2): 102-108)

• Adapted by Russell N. Olmsted, MPH, CICDirector of Infection Prevention & Control Services, St. Joseph Mercy Health

System (SJMHS), Ann Arbor, MichiganPresident, Applied Epidemiology Solutions, Inc. Ann Arbor, MIIntermittent Consultant Working with Patton Healthcare Consulting

To best learn from a defect, begin by identifying a problem through one of the following ways:

• Patient Safety Rounds• Defects identified in huddles• Employee concerns• Problems entered in VOICE• Problems with equipment or

supplies

• Infection control issue• Ask: How is the next patient

going to be harmed?• A concern shared by a patient

or family member• Other issues / problems / risks

identified in your area.

Then take time to discuss:

• What happened?• Why did it happen?• What factors

contributed? • What prevented it from

being worse? • And, What happened to

cause the defect?

• What can we do to reduce the risk of it recurring with different caregivers / team members?

• How will we know the risk was reduced?

• With whom should we share learning?

Root causes, failures, defects, workarounds, or undesired

variation……Are usually caused by one or more

of the following……

• Poor process design• Poor transfer of knowledge• Poor validation of competency• Poor measurement of conformance• Poor management intervention

Intervention(appropriate action)

LI

NE

MA

NA

GE

RS

Measure conformancePI staff

EducateStaff dev.

Validate competencyStaff dev.

Focus/PDSA/Rapid cycle design

PI team

5 Steps to doing the Right Thing Well Sustained Execution=Continuous Readiness

Measure conformance

• Poor design?

• Inadequate education

• Ineffective competency validation

• Variation due to work-arounds

• Variation due to unit, day of week, time of day, FT/PT/agency staff, etc.

John R. Rosing, MHA, FACHE

Patton Healthcare Consulting

QUESTIONS?

JohnRosing@PattonHC.com262-242-3631

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