The analytic work

• Select a team that will see the RCA² process through from beginning to end, including:
  • A subject matter expert; you may have to go outside your facility to find the right person;
  • A leader well-versed in the RCA² process;
  • Individual(s) not familiar with the event under review;
  • Front line staff working in the area/process, but not staff directly involved in the event; and
  • A patient representative who was not involved in the event under review.
• The team’s work should take place during the normal week schedule to send a clear message that management values and supports this activity to improve patient safety.

Patients and families, if able and willing, are among the most important witnesses for many adverse events. Interviewing them will enable the team to gain a more complete understanding of the event’s circumstances and may offer additional perspectives on how to reduce the risk of recurrence.

• Graphically describe the event using a chronological flow diagram or timeline based on preliminary understanding of event.
• Identify gaps in knowledge about the event.
• Visit the location of the event to gain firsthand knowledge about the workspace and environment.
• Evaluate equipment or products that were involved.
• Identify team-generated questions that need to be answered.
• Use triggering questions and other open-ended questions that can broaden the scope of the review.
• Identify staff who may have answers to the questions and conduct interviews of involved parties. These interviewing tips may be helpful.
• Include patients, family, and/or a patient representative as appropriate to ensure all facts are understood.
• Identify and review internal documents (e.g. policies, procedures, medical records, maintenance records).
• Identify and review pertinent external documents or recommended practices (e.g. peer reviewed publications, manufacturers’ literature, professional organization guidance).
• Identify and acquire appropriate expertise to understand the event under review. This may require interactions with internal and external sources of expertise (e.g., manufacturers, vendors, regulatory agencies).
• Update flow diagram or timeline to reflect final understanding of the events and where hazards or system vulnerabilities are located. Circulate the diagram or timeline with involved parties to ensure accuracy.

While it may be true that a human error was involved in an adverse event, the very occurrence of a human error implies that it can happen again. Human error is inevitable. If one well-intentioned, well-trained provider working in his or her typical environment makes an error, there are system factors that facilitated the error. It is critical to gain an understanding of those system factors to find ways to remove them or mitigate their effects.

Here are two helpful tools:

• The 5 rules of causation; and
• Cause and effect diagramming.

Don't try to censor your own ideas. The team’s job is to identify and recommend the most effective actions possible. It is then leadership’s responsibility to weigh questions about risks, benefits, opportunity cost and impact on the system in general.

• Use this action hierarchy tool to help develop your corrections actions plan.
• Share feedback with — and solicit additional ideas from — patients and/or families involved in the event, as well as involved staff and managers responsible for the process or area.
• After incorporating feedback, the RCA² team should have final decision authority over its findings and recommendations.
• If the event you are analyzing was reported to the Massachusetts Department of Public Health as an SRE, learn more about incorporating your findings and action plan into the final 30-day report to the department.