title: Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?
abstract: Despite over a decade of efforts to reduce the adverse event rate in healthcare, the rate has remained relatively unchanged. Root cause analysis (RCA) is a process used by hospitals in an attempt to reduce adverse event rates; however, the outputs of this process have not been well studied in healthcare. This study aimed to examine the types of solutions proposed in RCAs over an 8-year period at a major academic medical institution.
  
  
  
  All state-reportable adverse events were gathered, and those for which an RCA was performed were analysed. A consensus rating process was used to determine a severity rating for each case. A qualitative approach was used to categorise the types of solutions proposed by the RCA team in each case and descriptive statistics were calculated.
  
  
  
  302 RCAs were reviewed. The most common event types involved a procedure complication, followed by cardiopulmonary arrest, neurological deficit and retained foreign body. In 106 RCAs, solutions were proposed. A large proportion (38.7%) of RCAs with solutions proposed involved a patient death. Of the 731 proposed solutions, the most common solution types were training (20%), process change (19.6%) and policy reinforcement (15.2%). We found that multiple event types were repeated in the study period, despite repeated RCAs.
  
  
  
  This study found that the most commonly proposed solutions were weaker actions, which were less likely to decrease event recurrence. These findings support recent attempts to improve the RCA process and to develop guidance for the creation of effective and sustainable solutions to be used by RCA teams.
authors.affiliation: MedStar Health, MedStar Institute for Innovation, Washington District of Columbia, USA.
authors.forename: Kathryn M
authors.initials: KM
authors.lastname: Kellogg
authors.affiliation: MedStar Health, MedStar Institute for Innovation, Washington District of Columbia, USA.
authors.forename: Zach
authors.initials: Z
authors.lastname: Hettinger
authors.affiliation: BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, USA.
authors.forename: Manish
authors.initials: M
authors.lastname: Shah
authors.affiliation: Department of Emergency Medicine/CSRU, University of Florida/Imperial College London, Jacksonville, Florida, USA.
authors.forename: Robert L
authors.initials: RL
authors.lastname: Wears
authors.affiliation: University of Rochester School of Nursing, Rochester, New York, USA.
authors.forename: Craig R
authors.initials: CR
authors.lastname: Sellers
authors.affiliation: Nationwide Children's Hospital, Columbus, Ohio, USA.
authors.forename: Melissa
authors.initials: M
authors.lastname: Squires
authors.affiliation: MedStar Health, MedStar Institute for Innovation, Washington District of Columbia, USA.
authors.forename: Rollin J
authors.initials: RJ
authors.lastname: Fairbanks
mesh_terms: D000046:Academic Medical Centers; D016208:Databases, Factual; D006801:Humans; D007591:Joint Commission on Accreditation of Healthcare Organizations; D019300:Medical Errors / Q000517:prevention & control* / Q000706:statistics & numerical data*; D009518:New York / Q000453:epidemiology; D061214:Patient Safety / Q000592:standards; D011183:Postoperative Complications / Q000453:epidemiology; D060891:Root Cause Analysis; D017751:Safety Management; D014481:United States
keywords: Medical error, measurement/epidemiology; Root cause analysis; Significant event analysis, critical incident review