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Getting to the root cause
Raymond GAETA
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Most physicians and other health-care professionals realize that medical errors remain an ever-present threat to patients' well-being. To successfully reduce and prevent errors, however, we must learn to view and deal with errors differently. When a patient receives the wrong medication, we know that an error has occurred, but we must recognize that other, less-obvious incidents constitute medical errors as well.
It is all too easy for us to dismiss an error as an isolated event that won't happen again. We rationalize that it was a single individual's mistake that occurred because of an unusual confluence of circumstances. Meanwhile, we never believe it could happen to us.
When we view medical errors in isolation, however, we miss the opportunity to really understand the nature of the problem and we overlook important themes that could help patients and health-care professionals in the future. The process of "root-cause analysis" is the mechanism by which we at Stanford Medical Center - and clinicians at many other medical centers - strive to learn from each event in the name of patient safety.
Rather than view the error as an isolated incident occurring at a single point in time, root-cause analysis expands the timeline and requires us to look further upstream from the event. This approach allows us to identify system problems that individually are not problematic but which, in combination, allow for the "unusual confluence of circumstances" that lead to medical errors.
A root-cause analysis is typically conducted by an interdisciplinary team of the individuals who witnessed or were otherwise involved in the incident. The focus of the analysis is to learn what we can do better next time. Root-cause analyses demonstrate that certain actions, behaviors and attitudes can contribute to catastrophic results under certain conditions. Viewing the problem in this "process flow" manner can reveal a pattern of error that would otherwise be attributed to unconnected events. Such insight can lead to valuable changes in policies and procedures so that no future patients are harmed.
In a case recently cited in the Annals of Internal Medicine, for example, a 67-year-old woman was admitted for cerebral angiography and mistakenly underwent an invasive cardiac electrophysiology study. Through a root-cause analysis, the team identified 17 distinct errors that led to the mix-up. No single error could have caused the event, but in combination with system weaknesses, the wrong patient was taken to the EP lab. The contributing errors included absent or misused protocols for patient identification and informed consent; faulty exchange of information among caregivers; and poorly functioning teams.
Performing a root-cause analysis can also be very beneficial in response to a "near-miss." No error occurred because one of our checks and balances intervened before a critical step. Although we applaud the vigilance that catches such errors in time, this vigilance should be the last level of security because a near-miss indicates that the overall system is not designed optimally. Reducing the number of near-misses is a key goal of root-cause analyses, and physicians and staff should be encouraged to report near-misses as well as actual errors. Ultimately, each event provides an opportunity to learn and to improve safety for our patients.
Physician participation in this process is crucial. We can learn about the perspective of other health-care providers, and the brainstorming that occurs can lead to profound changes in how we care for our patients. Accordingly, physicians should embrace this type of analysis as a tool that will help ensure the safety of their patients.
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