Root Cause Analysis

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Root Cause Analysis A Tool for Improvement Wednesday, October 11, 2006 North Dakota Health Care Review, Inc. Center for Rural Health, UND School of Medicine Introduction • Objective – Demonstrate one method for conducting a root cause analysis – Describe tools and techniques that help analyze breakdowns in work processes • Outcome – You will be able to prepare an action plan for conducting a root cause analysis (RCA) in your local setting What is Root Cause Analysis? • A step by step questioning process to identify the basic or causal factors of an error or “near miss” • Used in high risk industries such as nuclear power, airlines, the military, and increasingly….in healthcare When Do We Use It? • When we need to understand and prevent Sentinel Events - Sentinel Event = “Unexpected occurrence involving death or serious physical or psychological injury, OR THE RISK THEREOF…” - Signals the need for immediate investigation and response. A Tool to Understand • What happened? • How did it happen? “Sharp End” • Why did it happen? • What can be done to prevent it from happening again? “Blunt End” “Blunt End” Organizations, Policies, Culture Resources and Constraints Stress Forgetfulness Fatigue Distraction Haste Assumptions “Sharp End” Patient Acceptable RCA • Acceptable if: – Focuses on systems – not people – Progresses from special cause to common cause – Digs deeper asking why, why, why – Identifies changes through re-design or new system What’s thorough? • Thorough if: – Human and other factors associated with event identified – Detailed inquiry into the key areas specific to the event – Identification of contributing factors and root causes – Determination of improvements What’s Credible? • Credible if: – Include participation/support from leadership and by individuals most closely involved in the processes and
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