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Preserving evidence essential to effective RCAs

Quality Improvement Monitor, April 25, 2008

A good root cause analysis (RCA) is akin to the investigations done on the hit television series “House.” You start off with a set of facts and drill down, using a cause-and-effect analysis, to discover what is truly making the patient sick.

“In the case of ‘House,’ it leads to a diagnosis,” says Gary Bonner, RN MBA, account manager at the Hopewell, VA–based Reliability Center, Inc., which provides hospitals with advice and software tools for conducting RCAs and Failure Modes and Effects Analyses (FMEA). “In the case of RCAs, it’s an acknowledgment of the root causes and the physical, human, and latent causes of that problem.”

Hospitals most often run into trouble with the first step of their RCAs -- preserving the evidence -- says Robert J. Latino, executive vice president at the Reliability Center.

“You can’t draw conclusions unless you have evidence to base it on,” Latino says. “It’s the most obvious step, but it’s the most overlooked, because that’s what takes the time. And we don’t have time.”

Access the full story in the April issue of the Quality Improvement Report; access is free for subscribers, nonsubscribers can purchase a copy of the story for $10.

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