By Erin Lawler, Human Factors Engineer and Kathleen Bateman, Patient Safety Specialist
When one of The Joint Commission’s then-physician executives developed the root cause analysis (RCA) framework, based on concepts from his experience as a NASA astronaut, the idea of its use during a global pandemic wasn’t even a thought.
The 24-question RCA tool was developed in 1988 with the goal of helping organizations complete a thorough analysis when safety events occurred. Dr. Rick Croteau, a former NASA engineer who had worked on the lunar landing, introduced tools like the RCA and failure modes and effects analysis (FMEA) approach when working at NASA, with a system/process analysis focus. The basis for the RCA framework originated from his NASA work around understanding failures. Elements of the FMEA process were used, with an emphasis on proactive risk reduction.
These tools formed the basis for the evaluation process of serious issues now known as “Sentinel events.” Much has changed at The Joint Commission since the RCA became health care’s primary event investigation tool in the 1980s, but the questioning why the event occurred still guides health care organizations through the drilling down process today.
Remarkably, as we wade through the impact of the COVID-19 pandemic and the sentinel event information we received from our accredited organizations (as described in this blog post) most organizations still used the framework to report possible sentinel events . For many organizations, the value-added piece during COVID was outlining:
- process steps that did not occur as intended
- communication issues
- human factors questions
Paradigm Shift in Acknowledging Error
It may seem obvious through a 2021 lens, but 25 years ago, there was widespread apprehension about discussing patient safety events.
Hospital attorneys were concerned that RCAs would not be completely confidential, leading to possible litigation which could have potentially revealed negligence or perceived wrongdoing by the hospital. It was difficult to know whether this information would be able to be used in lawsuits. Despite state law peer review statutes in all states, there was apprehension that if confidential information was shared outside a legal forum, it would no longer qualify as protected under attorney-client privilege.
In next month’s blog post, our Office of Federal Relations will delve more deeply into the legislation that ultimately helped organizations discuss potential patient harm events without fear of repercussion. The RCA tools were the first recognition that the only way health care organizations could improve is by dissecting the harm event and learning from what went wrong, thus preventing future errors.
Erin Lawler is the Human Factors Engineer in the Office of Quality and Patient Safety in the Division of Healthcare Improvement. Prior to joining The Joint Commission, Ms. Lawler served as the Human Factors Engineer for the Department of Defense Patient Safety and Analysis Center where she provided human factors consultation and data analysis. She also designed patient safety curricula in systems thinking and human factors, performing root cause analyses and proactive risk assessment, and understanding harm classification.
Kathleen Bateman is a Patient Safety Specialist in the Office of Quality and Patient Safety at The Joint Commission.