Explain each of the six steps used to conduct an RCA, as defined by IHI.
1. Explain each of the six steps used to conduct an RCA, as defined by IHI.
2. Apply the RCA process to the scenario to describe the causative and contributing factors that led to the sentinel event outcome.
A & A1 responses provide general information, and do not relate to the scenario. Describe in your own words. A numbered list can be used for A1.
For A2 apply Steps 1-4 of the RCA process to the scenario being sure to conclude with the causative and contributing factors.
Step 1: Identify what happened. The team must try to describe what happened accurately and completely. To organize and further clarify information about the event, some teams create a flowchart, a simple tool that allows you to draw a picture of what happened in the order it occurred.
Step 2: Determine what should have happened. The team has to determine what would have happened in ideal conditions. It can be useful to create a flow chart based on this information and compare it to the chart from Step 1.
Step 3: Determine causes (“Ask why five times”). This is where the team determines the factors that contributed to the event. Teams look at direct causes (most apparent) and contributory factors (indirect in nature) during this process. Some experts recommend that RCA teams “ask why five times” to get at an underlying or root cause. The IHI Open School provides online courses in quality improvement, patient safety, leadership, patient- and family-centered care, managing health care operations, and population health. These courses are free for students, residents, and professors of all health professions, and available by subscription to health professionals. One useful tool for identifying factors and grouping them is a fishbone diagram (also known as an “Ishikawa” or “cause and effect” diagram), a graphic tool used to explore and display the possible causes of a certain effect. Seven different factors influence clinical practice and medical error: patient characteristics, task factors, individual staff member, team factors, work environment, organizational and management factors, institutional context.
Step 4: Develop causal statements. A causal statement links the cause (identified in Step 3) to its effects and then back to the main event that prompted the RCA in the first place. By creating causal statements, we explain how the contributory factors – which are basically a set of facts about current conditions – contribute to bad outcomes for patients and staff. A causal statement has three parts: the cause (“This happened …”), the effect (“ … which led to something else happening …”), and the event (“ … which caused this undesirable outcome”).
Step 5: Generate a list of recommended actions to prevent the recurrence of the event. Recommended actions are changes that the RCA team thinks will help prevent the error under review from occurring in the future. Recommendations often fall into one of these categories: i. Standardizing equipment ii. Ensuring redundancy, such as using double checks or backup systems iii. Using forcing functions that physically prevent users from making common mistakes iv. Changing the physical plant v. Updating or improving software vi. Using cognitive aids, such as checklists, labels, or mnemonic devices vii. Simplifying a process viii. Educating staff ix. Developing new policies Some actions are more effective than others at dealing with the root causes of error. The National Center for Patient Safety defines strong, intermediate, and weak actions: i. A strong action is likely to eliminate or greatly reduce the likelihood of an event. ii. An intermediate action is likely to control the root cause or vulnerability. iii. A weak action by itself is less likely to be effective.
Step 6: Write a summary and share it. This can be an opportunity to engage the key players to help drive the next steps in improvement. To organize and further clarify information about the event, some teams create a flowchart, simple tool that allows you to draw a picture of what happened in the order it occurred.