Gary Oftedahl: Beyond RCA, we need more than a hammer
In today’s increasingly complex health care environment, with a rapidly proliferating capacity to provide effective, but complicated care, there is an associated increased risk to the patients we serve. Patient care, in almost any setting, is an inherently hazardous endeavor. Since the sentinel IOM report, To Err Is Human, was published, there has been an increasing focus on addressing safety.
The need to develop systems which both provide effective care, but also minimize the risk to our patients of an untoward effect is obvious. However, even under the conditions of vigorous efforts at risk assessment, the actual outcomes of complex systems will often surprise their designers, often with tragic consequences. There is increased pressure on health care systems to develop effective safety programs which can assess and learn from both the consequences of unexpected events, but also from the near misses often seen in health care. In my previous days as a practicing physician, we viewed the near misses with a sense of relief and moved on to another day, accepting the inevitable likelihood that these near misses and unexpected accidents were an accepted part of medicine. After all, we’re dealing with people, from a patient, health care worker, and physician perspective, and errors will occur.
Since the IOM report, we’ve seen an increased focus on avoiding “never” events, occurrences which should never happen, under any circumstances. Indeed, in Minnesota, there is a list of 28 “never” events developed by the Minnesota Department of Health which require submission of a report of their occurrence, and the actions taken to evaluate the cause of said episodes, linked to a “corrective action” (http://www.health.state.mn.us/patientsafety/ae/index.html).
I would suggest that our ability to assess and address the issues leading to these “never” events is limited by the tools we use in our evaluation. Our capacity to identify methods and processes which deal with the increased risk of unexpected human and system errors is exceeded by the rapidity of development of new and complex opportunities for error. An old adage notes that “If the only tool you have is a hammer, every problem looks like a nail.” In health care, we have emphasized the use of RCA (root cause analysis), with a recent increased focus on FMEA (Failure Mode and Effects Analysis) in investigating the cause of both the “never” events and in some more progressive institutions, the ”near misses” which may eventually lead to a more serious eventual incident.
While valuable at a certain level, we in health care still tend to understand errors in terms of breaches of personal and professional accountability. Few of us have received or understand the types of systems-based issues, human factors engineering, and human behavioral science which would enrich our ability to delve deeper into the complexity of systems and personal issues which led to an unfortunate never event.
In looking at other high reliability organizations (described by Karl Wieck and Kathleen Sutcliffe in their sentinel book, Managing the Unexpected) we see the need for immediacy, completeness, and commitment to a process which is transparent, part of the culture, and cognizant of the limitations of human behavior. In health care, we still see surgeons believing that they’re capable of functioning in a fully alert manner after 36 hours of uninterrupted calls, multiple major surgeries, and emerging fatigue.
There are opportunities to move forward in identifying tools other than the “hammers” we see in RCA and FMEA. I’m not belittling their role, and their value at a certain degree, but we need to move beyond accepting them as the gold standard in risk assessment. In fact, while bemoaning their limitations, we rarely see these tools applied in a systematic fashion in many institutions. Rather than focusing on a single root cause, we need to further our understanding of the complexities of human behavior, the intricacies and convolutions of our processes, and the need to move from solely personal and professional accountability as a driver of our efforts.
At the Institute for Clinical Systems Improvement (ICSI) we’ve been involved in working on safety and learning more about what tools might be valuable in expanding our ability to address it. While understanding the value of RCA and FMEA, we need to consider the possibility that there are other aspects of evaluation which may be necessary to add to our “toolbox.” In light of this, we’re delighted to have Mike Silver, a human factors expert from the Utah/Nevada QIO (HealthInsight) leading a workshop on November 11, 2009 (http://www.icsi.org/calendar/workshops/beyond_rca.html) providing us information on human factors applications, fault tree and causal tree analysis, and applied behavioral analysis, as potential levers in increasing our capacity to address the multiple causes which may be leading to the unexpected, and dreaded never events. It’s only a start, but I really don’t want to be stuck with only having a hammer, when the world requires a more elegant set of tools.
The focus on health care reform is essential, but we need to continue to focus on how we can ensure that our patients are not only receiving the most appropriate and valuable care, but also the safest. Going to a clinic or being admitted to a hospital should not be considered risky behavior. Unfortunately at our present level of understanding of errors, and addressing them, it is the norm not the exception to have that perception. It is our challenge and responsibility to ensure our toolkit is equipped with the best and most modern “tools” in creating the safe environment our patients expect.