Root Cause Analysis of Surgery-Related Adverse Events
Dr Paul Barach (MD, MPH) & Bryce R Cassin (RN, AFCHSM)
The conversation related to patient safety has gained currency in the last decade and
incident investigation processes have been implemented by health care organizations
internationally to improve the safety of clinical care delivery.2 The most common
method used as a primary means of investigating serious adverse events is root cause
analysis (RCA).3 The Institute of Medicine’s (IOM) report, To Err is Human, stated that
“root causes are complicated by the fact that several interlocking factors often
contribute to an error or series of errors that in turn result in an adverse event.”4
Two significant facts emerge from this quotation: the IOM investigators view error
as causally linked to medical management (or rather, bad systems) and that the
complication they describe is one of collecting administrative data for the purpose
of raising awareness of the issues, not taking specific action to better understand the clinical workplace.
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