title: Hamilton acute pain service safety study: using root cause analysis to reduce the incidence of adverse events.
abstract: BACKGROUND
  Although intravenous patient-controlled analgesia opioids and epidural analgesia offer improved analgesia for postoperative patients treated on an acute pain service, these modalities also expose patients to some risk of serious morbidity and even mortality. Root cause analysis, a process for identifying the causal factor(s) that underlie an adverse event, has the potential to identify and address system issues and thereby decrease the chance of recurrence of these complications.
  
  
  METHODS
  This study was designed to compare the incidence of adverse events on an acute pain service in three hospitals, before and after the introduction of a formal root cause analysis process. The "before" cohort included all patients with pain from February 2002 to July 2007. The "after" cohort included all patients with pain from January 2009 to December 2009.
  
  
  RESULTS
  A total of 35,384 patients were tracked over the 7 yr of this study. The after cohort showed significant reductions in the overall event rate (1.47 vs. 2.35% or 1 in 68 vs. 1 in 42, the rate of respiratory depression (0.41 vs. 0.71%), the rate of severe hypotension (0.78 vs. 1.34%), and the rate of patient-controlled analgesia pump programming errors (0.0 vs. 0.08%). Associated with these results, the incidence of severe pain increased from 6.5 to 10.5%. To achieve these results, 26 unique recommendations were made of which 23 being completed, 1 in progress, and 2 not completed.
  
  
  CONCLUSIONS
  Formal root cause analysis was associated with an improvement in the safety of patients on a pain service. The process was effective in giving credibility to recommendations, but addressing all the action plans proved difficult with available resources.
authors.affiliation: From the Department of Anesthesia (J.E.P., N.B., R.F.M., L.T., D.M., J.C.) and Department of Clinical Epidemiology & Biostatistics (L.T.), McMaster University (K.A.), Hamilton, Ontario, Canada; Acute Pain Service-NP, St. Joseph's Healthcare (K.A.), Hamilton, Ontario, Canada; Clinical Practice and Education (M.K.), Hamilton Health Sciences (D.B., M.M.), Hamilton, Ontario, Canada; Advisor Health System Transformation, Hamilton Niagara Haldimand Brant Local Health Integration Network (R.F.), Grimsby, Ontario, Canada.
authors.forename: James E
authors.initials: JE
authors.lastname: Paul
authors.forename: Norman
authors.initials: N
authors.lastname: Buckley
authors.forename: Richard F
authors.initials: RF
authors.lastname: McLean
authors.forename: Karen
authors.initials: K
authors.lastname: Antoni
authors.forename: David
authors.initials: D
authors.lastname: Musson
authors.forename: Marianne
authors.initials: M
authors.lastname: Kampf
authors.forename: Diane
authors.initials: D
authors.lastname: Buckley
authors.forename: Michelle
authors.initials: M
authors.lastname: Marcoux
authors.forename: Rosemary
authors.initials: R
authors.lastname: Frketich
authors.forename: Lehana
authors.initials: L
authors.lastname: Thabane
authors.forename: Ji
authors.initials: J
authors.lastname: Cheng
mesh_terms: D016058:Analgesia, Patient-Controlled / Q000009:adverse effects*; D000701:Analgesics, Opioid / Q000009:adverse effects*; D000767:Anesthesia, Epidural / Q000009:adverse effects*; D015984:Causality; D015331:Cohort Studies; D006801:Humans; D007022:Hypotension / Q000139:chemically induced / Q000517:prevention & control; D007260:Infusion Pumps; D010146:Pain / Q000188:drug therapy; D018710:Pain Clinics / Q000458:organization & administration*; D061214:Patient Safety; D011446:Prospective Studies; D012131:Respiratory Insufficiency / Q000139:chemically induced / Q000517:prevention & control; D060891:Root Cause Analysis; D016896:Treatment Outcome
chemical_list: D000701:Analgesics, Opioid