Latest / Safe As Podcast / E15: Root Cause Analyses (RCA) and incident prevention: do they work?

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E15: Root Cause Analyses (RCA) and incident prevention: do they work? · Safe As Podcast

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  In industry, root cause analysis, or Rcas, are a widely
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  used collection of approaches and tools.
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  They're meant to be a rigorous process for digging deep after
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  an adverse event, identifying contributing factors in crafting
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  solutions that will prevent reoccurrences.
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  The expectation is that an RCA leads to real, tangible
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  improvements. But what does the latest
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  research actually show about the effectiveness of Rcas?
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  Are Rcas consistently delivering on their promises to make our
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  workplaces safer? Or are we sometimes just going
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  through the motions without seeing the desired impact?
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  Good day, everyone. I'm Ben Hutchinson, This is Safe
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  as a podcast dedicated to the thrifty analysis of safety,
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  risk, and performance research. Visit safetinsights.org for more
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  research. Today's study is from Martin
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  Delgado ET al 2020, entitled How much of Root Cause analysis
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  translates into improved patient Safety?
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  A systematic review published in Medical Principles and Practise.
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  It's a systematic review that explored whether root cause
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  analysis are effective to reduce your recurrence of avoidable
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  adverse events in healthcare, or else call them adverse events.
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  21 studies were included, nine of moderate quality, 5 of
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  considerable quality, seven of high quality.
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  It's another healthcare study. As you picked up, it's worth
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  highlighting that RCA is an umbrella term.
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  It's not some monolithic tool, but rather includes many
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  different tools and methods. Because of this study design and
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  the overall limited evidence, they couldn't sort the study
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  into a comparison of the specific RCA tools.
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  So what did they find? Overall, they found the
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  effectiveness of Rcas is unclear and inconsistent.
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  According to the paper, it's not clear if root cause analysis is
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  effective in preventing the recurrence of adverse events.
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  And although early studies suggested that Rcas are
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  effective in promoting ideas for preventing recurrence, more
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  recent studies don't confirm these findings.
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  Put simply, we're not seeing stronger or more consistent
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  evidence that RCA processes are actually help prevent future
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  harm. Further in the details, in only
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  two studies could it be established that Rcas
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  contributed to the improvement of patient care to some extent.
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  And these two studies were themselves limited by the number
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  of the Rcas reviewed, really weakening the evidence overall.
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  Also, they found in 50% of the cases the recommendations from
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  the Rcas were quite weak, which didn't lead to a reduction of
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  adverse events. So half of the time the outputs
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  from the Rcas aren't even strong enough to really have any
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  tangible improvements of the things they're supposed to
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  actually help prove. They also found that the action
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  plans saw the corrective actions are really poorly designed and
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  untested. One study found that action
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  plans didn't follow any controlled implementation
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  pattern, so no link could be established between the plans
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  and actual tangible operational improvements.
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  Put simply, the fixes that result from these RCA processes
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  may be too flawed or too poorly implemented to really help
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  improve operational outcomes, and maybe they can even create
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  some new ones. Also, they found that most of
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  the recommendations ignored deeper systemic issues.
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  For instance, most of the proposed recommendations focused
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  on active errors from people and neglected latent contributing
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  factors. So the focus on people provides
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  maybe short term solutions, but really only partially helps to
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  avoid future problems. It's not really improving the
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  conditions that people work in. So instead of addressing system
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  flaws, these RCA processes, according to this research,
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  often results in blaming frontline staff of a really
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  shallow solutions. They also found there was a
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  strong lack of follow up and verification of the
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  improvements. So the RCA processes didn't
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  really require any cheques to see whether the improvements
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  were actually carried out. This disconnect undermines A
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  usefulness. Without follow up, even good
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  recommendations can fail. Not surprisingly, back down that
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  there was quite low involvement from those closest to the
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  incident. So managers and personnel
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  involved in the actual adverse events had low participation
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  rates in the investigation teams.
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  This limited not only their insight into what was actually
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  happening, but also reduced potential psychological recovery
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  for second victims and those emotionally affected by the
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  incident. Put another way, leaving out
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  frontline staff leads to weaker analysis and missed chances for
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  healing and improving. And they found that blame
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  culture really discourages reporting and RCA participation.
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  So they found cultures that they were really focused on searching
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  for guilty party, those responsible.
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  And this created tensions in the work environments that really
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  challenged interprofessional relationships.
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  His fear and lack of trust LED professionals to refuse to even
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  participate in the incident processes.
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  Simply put, if people fear punishment, they won't speak up.
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  So in conclusion, Rcas well may be useful for some things can
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  really lead to very remote and immediate fixes, but they don't
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  seem to be very effective for long term or effective
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  implementation measures to prevent the reoccurrence of
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  incidents. And although some studies have
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  demonstrated the usefulness of Rcas and in the recommendations,
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  most of the published studies in at least in this study in
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  healthcare found that just over half of the recommendations
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  weren't even useful enough to prevent the same incidents from
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  recurring in the future. They were disconnected from the
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  things that they were supposed to be focusing on and fixing.
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  So they conclude that RCA approaches can potentially help
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  understand some contributing factors, but they often failed
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  to help with the fixes or fix the issues.
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  In contrast, the fixers tend to be really weak, shallow, or even
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  I'll suited to improve these complex environments like
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  healthcare. So what do we make of these
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  findings? Well, again, it's not one tool.
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  RCA covers a lot of ground. In any case, I think we really
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  need to be clear around on what we want the RCA processes to
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  achieve, can achieve, should achieve and evaluate whether our
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  processes are configured for those results.
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  Do we have any unfair expectations or unrealistic
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  expectations around what we want them to be able to achieve?
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  Do we even have the right resources and expertise?
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  Maybe a shake up is needed. Do we need less investigations
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  and maybe more proactive learning?
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  Do we need better feedback and engagement channels with workers
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  or design level interventions? What about different teams being
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  involved or trying different tools and approaches?
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  And maybe instead of building a shopping list of contributing
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  factors and detailed timelines that will benefit few, maybe
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  spend more time on learning about daily work, the
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  constraints and designing in better, safer work.
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  Importantly, work that I covered previously from Lundberg
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  suggested that investigations, probably like most processes in
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  organisations, are affected by a host of sociopolitical factors
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  separate to the incident itself, but still significantly impact
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  what investigations find they construct and ultimately try and
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  fix. Maybe to a degree some of these
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  constraints are just fundamental limits within organisations.
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  So for limitations there was a few, but I think the main 1
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  really is there's a relatively limited body of evidence on Rcas
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  and how what they actually change in occupational settings,
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  also unlike a broken record. But there's also the issue with
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  using statistically rare events like incidents.
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  It's a huge limitation. It's just really difficult to
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  connect upstream factors with downstream outcomes.
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  However, a number of other healthcare RCA studies using
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  different measures like corrective action quality also
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  find widespread and systemic issues with the RCA approaches.
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  That's it on Safe. As I'm Ben Hutchinson, please
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  help share, rate, and review, and check out safetyinsightsorg
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  for more research. Finally, feel free to support
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  Safe ads by shouting a coffee link in the show notes.