The aim of hospital care is to provide appropriate and safe service for patients. Nevertheless, up to 10% of acutely admitted patients are involved in adverse incidents and can therefore be unintentionally harmed[1–3]. Remarkably, up to two thirds of all adverse incidents take place in surgery, more than half of which may be preventable. Prevention efforts depend on the detailed knowledge of the aetiologies of these events.
It is generally considered that errors are multifactorial in nature and that they occur due to a failure of the system rather than because of the failure of an individual in performing their task per se. RCA is a method for retrospective analysis of systematically collected data regarding incidents with an aim to determine the main cause(s) of errors and to identify system or process weaknesses that contributed to or allowed an adverse event[9, 15]. Reviewing adverse incidents with the involved members of staff is thought to allow a better understanding of the aetiologies of incidents by identifying the so called “root cause”. The purpose of RCA is to answer three key questions: What was the adverse incident? How did it occur? Why did it occur?[9, 15, 16].
Literature defines root cause as the element that, if corrected, would prevent similar incidents from happening and assists in determining a management plan should the same or a similar incident occur[5, 9]. However, based on the fact that almost all adverse incidents are multifaceted in nature, the terms root cause and RCA seem to be misnomers[7, 8, 16]. In addition, RCA as a term implies that the sole aim of investigation is to discover what caused an adverse incident, whereas the main principle behind this process is to reveal inadequacies in the healthcare system and look at the broader picture. Nevertheless, it is readily used in the English literature and we have not broken this tradition in our report.
Considering the complex nature of the aetiologies of adverse incidents, when an adverse incident occurs, it would be inappropriate to place blame on individuals. RCA is a method whereby focus is placed on mutual learning and in-depth discussions regarding the incident in a non-threatening and non-blaming environment[7, 12, 17]. There is evidence that if performed correctly, RCA is of great value in identifying root causes, facilitating incident management and error reduction, thereby optimising patient care and safety in a healthcare system[10, 15]. It is therefore an extremely valuable tool in disposal of modern healthcare.
Institutions perform RCA using either a “team-based” or “investigator led” methods. There are certain merits to the team-based approach compared to the investigator led method. In the latter method, an investigator assembles the relevant information relating to the incident and reports to the management team so that the relevant changes can be implemented. However, in many centres it is now felt that a team of investigators with a wide spectrum of skill and backgrounds e.g. risk managers and clinicians should perform RCA in particular in relation to the serious adverse incidents using a predetermined protocol. This would allow for a more effective and thorough analysis of incidents, as supported by our findings.
According to Reason’s model of human errors, the team of investigators should take 3 important factors into consideration for the investigation: Care management problems (i.e. actions taken by members of staff that is thought to have led to the occurrence of the incident), the clinical context of the incident and any factors contributing to its occurrence[12, 16]. A chronological flow chart of the incident is then drawn, so as to tease out where the system failed. The team then analyses the incident, identifies possible aetiologies, and devises plans to address any issues, aiming to ensure that a similar incident will not occur. The incident reporter is then contacted with a course of action. After the implementation of the plan, feedback is provided to ensure the effectiveness of recommendations[12, 16] . RCA must be considered as an important duty, which would require sufficient time and active input by the members of the team.
Despite the benefits that RCA offers, certain limitations exist. Although it aims to answer the 3 important questions mentioned earlier, in many circumstances it does not seem to reduce the risk of an adverse incident recurring at a later date. Therefore adverse incidents frequently recur despite time and resource consuming RCAs. It often suffers from hindsight bias; adverse incidents are perceived to be more predictable after they have taken place, whereas in reality this is usually not the case[9, 19].
RCAs are time and resource consuming. Many incidents are multifactorial in nature and determining a root cause is a great challenge[9, 13]. Other reported limitations of this system include: uncooperative colleagues, inter-professional differences, poor software performance, lack of structured reporting and unsupportive management. Furthermore, it is very difficult to follow-up the outcomes and recommendations achieved from RCA. Experience has shown that recommendations are not always adhered to in clinical practice and incidents repeat themselves despite good quality RCA and recommendations. In support of this argument, our study revealed repeated similar reports from the same sources. RCA should result in recommendations, which need to be implemented in clinical practice, in order to be cost-effective. For this purpose, active support from the management is required and the necessary resources need to be provided; otherwise the likelihood of improvement is limited.
Reporting incidents can be challenging. Staff members often have concerns about personally admitting a mistake and worry about penalty or litigation. Moreover, it is often difficult to categorise incidents according to their severity, and they are often incorrectly, incompletely and/or incoherently recorded on the database. In our study more than 50% of the reported incidents were of inadequate quality. Certain centres have provided Safety Improvement Programmes (SIP) for training staff in incident reporting with a focus to improve their RCA results. The SIP covers topics such as: incident identification and prioritisation, systematic notification of incidents to the individuals concerned, investigation using the RCA approach, actions required regarding recommendations, feedback of the collected data to the system and appropriate discussion regarding sentinel incidents. Evidence in the literature suggests that SIP improves the quality of incident management thereby leading to error reduction[10–12, 21]. Reports from U.K. hospitals, included exemplary practice of RCA in only 2 of the 7 centres studied (29%), less rigorous practice in 3 (43%) and scanty practice in the other 2 units. The reports showed a definite correlation between training and the quality of RCA[21, 22].
Our study demonstrates certain deficiencies of the quality of incident reports, the ratio of sentinel incidents that underwent RCA and the implementation of changes in clinical practice. We discovered that a significant number of incident reports were of poor quality, a fact that can adversely affect the outcome of a subsequent RCA. To improve the quality of incident reports, we recommend targeted formal training of staff members in incident reporting. Sentinel incidents should be reported shortly after their occurrence which, would in-turn allow for an early RCA, and the potential recommendations would hopefully prevent the recurrence of similar incidents as early as it may be possible. Hospital management should take a more active role in ensuring that any recommendations are implemented in clinical practice. The decision for an in-depth analysis of sentinel incidents was variable and depended on the subjective judgement of a designated reviewer. A predetermined protocol for the analysis of sentinel incidents would certainly contribute to improved results. Furthermore, the inconsistency of the incident report reviewers in terms of training and experience in RCA may have led to discrepancy in the quality of RCAs, and may have affected the implementation of recommendations.