Authors (including presenting author) :
Kwok YTA(1), Wong PMB(1), Kwan WM(1)
Affiliation :
(1)Quality and Safety Division, New Territories West Cluster
Introduction :
In the New Territories West Cluster (NTWC), root cause analysis (RCA) is conducted for investigation of sentinel events (SEs), serious untoward events (SUEs) and other significant incidents. The conduction of RCA was known to be time and resource-consuming. However, there had been no evaluation on the effectiveness of RCA recommendations in the past.
Objectives :
To study the strength and effectiveness of RCA recommendations and identify ways for improvement.
Methodology :
All RCA reports investigating incidents occurred in the NTWC between January 2013 and November 2018 were analyzed. The type and strength of recommendations in RCA reports were coded according to the RCA Tools from the National Center for Patient Safety Department of Veteran Affairs, US. A recommendation will be categorized as a ‘strong’ one if it is best at removing the dependence on the human, while it will be a ‘weak’ action if the recommendation heavily relies on human.
Result & Outcome :
111 RCA reports were analyzed. 64 (58%) of them were related to medication process, 42 (38%) were related to other clinical services and 5 (5%) were related to administrative services. For the root causes, 80 (26%) of them were task factors while 78 (26%) and 43 (14%) of them were staff and education/training factors respectively. 485 recommendations were raised in these 111 RCA reports. Of these, 64 (13%) were ‘strong’, 181 (37%) were ‘medium’ and 240 (50%) were ‘weak’. Further, 68 (61%) out of the 111 RCAs only had ‘weak’ and ‘medium’ recommendations, i.e. no ‘strong’ recommendations. 10 RCAs (9%) even had ‘weak’ recommendations only. Among all recommendations, the most frequent ones were training and education (196 (40%)) (a ‘weak’ recommendation) and review/enhancement of policy/guideline/documentation (62 (13%)) (a ‘medium’ recommendation). The study found that most of the recommendations identified in the RCAs were not strong. Possible reasons would be the ending of investigations after an active human error was identified (i.e. latent system factors not explored). This was evident that 40% of root causes were human-related. Other factors include cost and lack of human factors expertise in the RCA panel. Management involvement, thematic analysis of RCA and regular review of recommendation effectiveness are therefore suggested to make RCA more meaningful. Further, the NTWC will be providing RCA training with guidance on strength of recommendations since February 2019.
Co-location with:
