Medical mistakes are common. While most medical errors are never noticed, some mistakes cause injury, prolonged treatment, or death. After a serious medical error, most institutions initiate a Root Cause Analysis (RCA) to explore the event.
According to the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network (PSNet), a root cause analysis is a “structured method used to analyze serious adverse events. Initially developed to analyze industrial accidents.” In the 1980’s, The Joint Commission began to develop a framework around the idea of root cause. A fundamental aim of the RCA is to gain an understanding of what happened to cause a serious or Sentinel event. Because the original process was designed for industrial settings, RCAs consider failures across the system, rather than pinpointing the fault of an individual.
Today, The Joint Commission and the institutions for which it provides accreditation use the RCA to identify factors that contribute or cause serious medical mistakes. Many hospitals have a Serious Safety Event Committee or similarly named group that is charged with conducting the RCA after an adverse medical event.
Serious medical mistakes are often the product of multiple failures. The factors considered within the structure of an RCA may include:
- Human factors
- Communication
- Process
- Management or organizational behavior
- Team or work environment
- Patient characteristics
- Regulatory/institutional issues
There is no magic in an RCA. The findings of a careful examination of what happened to cause patient harm cannot undo the harm done. That said, an RCA is a powerful tool for helping a facility prevent a similar event going forward. The findings of an RCA translate to recommendations and systemic changes that help physicians and institutions make changes to try and avoid similar system breakdown and medical error.
When the RCA processes were new to the industry decades ago, hospitals were concerned that RCA findings could be made public. It is important to note that the findings of an RCA are not legally available to patients who have been harmed by medical malpractice. In knowing what caused harm, facilities are better able to prevent harm in the future.
As noted, an RCA cannot undo injury, disability, or death caused by medical error. If you, or a loved one, suffered serious medical harm—speak with an experienced medical malpractice attorney with our firm.
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