Supporting staff, physicians, and other providers to advance a culture of safety is the focus of the University of Minnesota Health Patient Safety team and one method utilized to support care improvement is Root Cause Analysis (RCA). RCA is a problem-solving technique utilized to identify the cause and corrective action surrounding a patient safety occurrence. The RCA process allows for an evidence-based understanding of the cause of error while reinforcing a culture of safety for patients, physicians and staff.
The RCA process is based on industry best practices and is initiated when an occurrence has been deemed as one of the following:
The University of Minnesota Health Patient Safety team begins the RCA process by reconstructing the situation surrounding the occurrence using investigative methods including: chart review; 1:1 interviews of individuals involved and subject matter experts; environmental assessment; and review of current policies and research. The information is collected and reported chronologically to aid in identifying deviations to process or areas for improvements. The “5 Whys” technique (an iterative series of “why” questions used to explore cause-and-effect) is then applied to each deviation to identify the defect. Each defect is then assigned one of two best practice taxonomies to guide root cause determination and corrective action planning.
The Patient Safety team, along with front line staff, clinical experts, the risk management and quality teams, and leadership review the findings and determine the root cause(s) that led to the occurrence. This interdisciplinary, collaborative approach allows for efficient problem solving and action planning, which may include individual follow-up, organizational changes and implementation plans.