Clinical errors: Implementing root cause analysis in an area health service

ABSTRACT

Introduction: Medical errors are considered as threatening the patients’ health and well-being in healthcare and treatment systems. There are various methods offered for managing the clinical risks and ensuring the healthcare quality and patient safety. Root cause analysis (RCA) is one of these methods. So, the current research paper aims at radically analyzing seven sentinel events reported to one of the large vice-chancellorships in Medical Sciences Universities in Iran.

Method: The present study is a descriptive research which has been carried out based on a qualitative-retrospective method according to the eight stages elaborated in root cause analysis of healthcare events determined by National Authority for Health. To classify the identified problems, there was made use of ‘classifying nursing errors in clinical management (NECM)’ model, error cause classification, approved by the UK National Health System and then an innovative problem-solving method was applied to determine the improvement solutions. The information about the items in RCA forms was collected after obtaining a consensus of experts’ panel views via interviews and focus group discussion sessions.

Findings: For the 7 sentinel events, 30 problems related to the service or healthcare was identified. Out of the 30 identified problems, the most problem related to care problems (45.4%) and the least frequent problem related to knowledge and skill problems (14.5%). Inter alia the 406 influential causes mentioned, the most frequent cause error modes pertained to organizational factors (20.1%) and the least frequent cause error modes referred to patient-related and patient-companion related factors (6.1%). Moreover, the highest rate of interventions was taken in such areas as human resources management and implementing and monitoring suitable changes in clinical processes.

Conclusion: According to the usefulness of error root cause analysis in regard to such issues as patients’ safety, the systematic evaluation of sentinel events and incidents in sectors offering healthcare and treatment services is recommended. It is evident that the success of the corrective interventions in healthcare and treatment centers depends on policy-making and corroboration of the executive and supervisory levers and it is not possible without full-scale coordination and support by the various sectors connected to the social health.

KEYWORDS:

• Patient safety
• root cause analysis
• medical error
• care delivery problem
• service delivery problem

Acknowledgements

We are thankful that this research was supported by Vice-Chancellor’s Office in Treatment Affairs in Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Disclosure statement

No potential conflict of interest was reported by the authors.

Contributors

All authors contributed to this project and article equally. Dr. Mirhashemi and Dr. Noorbakhsh conceived of the presented idea. Vahidi and Molavi Taleghani developed the theory and performed the computations. Molavi and Dr. Noorbakhsh verified the analytical methods.. All authors discussed the results and contributed to the final manuscript. All authors read and approved the final manuscript.