Root Cause Analysis and Actions for the Prevention of Medical Errors: Quality Improvement and Resident Education

Early ambulation protocol after diagnostic transfemoral cerebral angiography: an evidence-based practice project

BACKGROUND

No uniform consensus has been achieved regarding the ambulation protocol after transfemoral cerebral angiography (TFA). Until now, in most hospitals patients are prescribed 8-12 h strict immobilization along with bed rest in the supine position after TFA in China, which causes great discomfort to patients.

OBJECTIVE

To evaluate the effect of an evidence-based early ambulation protocol on the prevention of vascular complications and general discomfort in patients following transfemoral cerebral angiography (TFA).

METHODS

A prospective quasi-experimental study was conducted on 214 patients undergoing TFA with manual compression. Patients in the experimental group were placed supine position for 2 h with a sandbag placed on the wound dressing, followed by a semi-seated position for another 2 h. After this period, patients took 2 h bed rest (move freely) with the sandbag removed, and were allowed to get out of bed 6 h after TFA. Patients in the control group were restricted to an 8 h bed rest in a supine position with the affected leg straight and immobilized. The vascular complications (bleeding, hematoma, ecchymosis) and levels of comfort (low back pain, leg pain, and blood pressure) were evaluated after the procedure. Numeric Rating Scale (NRS) pain scores, systolic blood pressure (SBP); diastolic blood pressure (DBP) were measured hourly for 8 h after TFA.

RESULTS

There was no significant difference in the two groups with regard to vascular complications including bleeding events (P = 0.621), bleeding volume (P = 0.321), and area of hematoma (P = 0.156). The area of ecchymosis in the experimental group was significantly smaller than the control group (P = 0.031). Compared with the control group, the NRS score for low back pain in the 4th, 5th, 6th, 7th, and 8th hour after TFA were significantly lower (P < 0.05), and the NRS score for leg pain in the 5th, 6th, 7th, 8th hour after TFA were significantly lower (P < 0.05). The SBP and DBP in the 6th, 7th, and 8th hour after TFA were significantly lower than the control group (all P < 0.05).

CONCLUSIONS

The evidence-based early ambulation protocol can effectively and safely increase comfort and decrease the pain level for patients undergoing TFA, without change in the incidence of vascular complications.

Effect of Patient Safety Curriculum for Internal Medicine Residents on a Health Care System

Background

Healthcare organizations seeking to promote a safety culture depend on engaged clinicians. Academic medical centers include a community of physicians-in-training; however, medical residents and fellows are historically less engaged in patient safety (PS) than are other clinicians. Increased attention has been focused on integrating PS into graduate medical education. Nonetheless, developing curricula that result in real-world system changes is difficult.

Objective

To develop an interactive PS curriculum for internal medicine (IM) residents that analyzes real-word PS problems.

Methods

A multidisciplinary group developed a five-session, case-based PS curriculum for IM residents in the context of a 3-year, longitudinal quality-improvement, PS, and high-value-care curriculum. The curriculum was facilitated by a PS analyst and incorporated mock root cause analysis (RCA) based on actual resident-reported PS events. Each mock RCA developed an action plan, and outcomes were tracked. Pre- and postcurriculum assessments with participating residents were conducted to evaluate the curriculum.

Results

Twenty-eight IM residents completed the curriculum during four iterations from 2017 to 2020. The curriculum identified multiple potential PS risks, led to tangible changes in clinical processes, and enhanced resident confidence in improving systems of care.

Conclusions

We describe an active-learning PS curriculum for IM residents that addressed actual resident-reported PS problems. Through RCA, action items were identified and meaningful system changes were made. Leveraging the expertise of local PS experts in the design and delivery of PS curricula may improve the translation of learner recommendations into real system changes and cultivate a positive PS culture.

Designing Actionable Solutions and Curriculum for Pain Disparities Education

The Liaison Committee on Medical Education (LCME) require medical schools to teach their students how to recognize and work towards eliminating health disparities. However, time constraints and a dearth of guidance for educators in teaching pain disparities curricula, pose significant challenges. Herein, we describe successes and lessons learned after designing, implementing, and evaluating an innovative pain disparities curriculum that was embedded in a longitudinal health equity curriculum for third year medical school students at an academic institution. Although the curriculum was developed for medical school students, the concepts may be broadly applicable to other training settings such as residency and fellowship programs.

Root-Cause Analysis of Mortality Following Pancreatic Resection (CARE Study): A Multicenter Cohort Study

OBJECTIVES

Analyze a multicenter cohort of deceased patients after pancreatectomy in high-volume centers in France by performing a root-cause analysis (RCA) to define the avoidable mortality rate.

BACKGROUND

Despite undeniable progress in pancreatic surgery for over a century, postoperative outcome remain particularly worse and could be further improved.

METHODS

All patients undergoing pancreatectomy between January 2015 and December 2018 and died post-operatively within 90 days after were included. RCA was performed in two stages: the first being the exhaustive collection of data concerning each patient from preoperative to death and the second being blind analysis of files by an independent expert committee. A typical root cause of death was defined with the identification of avoidable death.

RESULTS

Among the 3195 patients operated on in nine participating centers, 140 (4.4%) died within 90 days after surgery. After the exclusion of 39 patients, 101 patients were analyzed. The cause of death was identified in 90% of cases. After RCA, mortality was preventable in 30% of cases, mostly consequently to a preoperative assessment (disease evaluation) or a deficient postoperative management (notably pancreatic fistula and hemorrhage). An inappropriate intraoperative decision was incriminated in 10% of cases. The comparative analysis showed that young age and arterial resection, especially unplanned, were often associated with avoidable mortality.

CONCLUSION

One third of postoperative mortality after pancreatectomy seems to be avoidable, even if the surgery is performed in high volume centers. These data suggest that improving postoperative pancreatectomy outcome requires a multidisciplinary, rigorous and personalized management.

The Mystery Dinner RCA: Using Gamification and Simulation to Teach Root Cause Analysis

INTRODUCTION

Root cause analysis (RCA) is a widely utilized tool for investigating systems issues that lead to patient safety events and near misses, yet only 38% of learners participate in an interdisciplinary patient safety investigation during training. Common barriers to RCA education and participation include faculty time and materials, trainee time constraints, and learner engagement.

METHODS

We developed a simulated RCA workshop to be taught to a mix of medical and surgical specialties from over 11 GME programs and to third-year medical students. The workshop was a single 90-minute session formatted as a gamified mystery dinner including characters and sequentially revealed clues to promote engagement. Participant satisfaction and subjective knowledge, skills, and attitudes were assessed with a pre/post survey.

RESULTS

The workshop was completed by 134 learners between October 2018 and October 2019. The short workshop duration and premade simulation allowed a small number of faculty to train a wide variety of learners in various educational settings. Participants' presurvey (124 out of 134, 92%) versus postsurvey (113 out of 134, 84%) responses showed that attitudes about RCA were statistically improved across all domains queried, with an average effect size of 0.6 (moderate effect); 91% of participants would recommend this course to a colleague.

DISCUSSION

A 90-minute, gamified, simulated RCA workshop was taught to medical students and multiple GME specialties with subjective improvements in patient safety attitudes and knowledge while alleviating faculty time constraints in case development.

Improvement of patient satisfaction by root cause analysis in health care services for urban slum community in North India

Universal health care (UHC) endorses availability and access to health care services for a wider population with equity and quality in a way that protects them from financial hardship while availing the services. This case study shares the experience of a health facility in a resource constraint setting catering to the health needs of a migrant residing in an urban slum of north India. Out-of-pocket expenditure is one of the major reasons for nonachievement of UHC. “Root cause analysis“ revealed the challenges for patient satisfaction in the academic outpatient clinic (OPD). Inadequate availability of laboratory investigations at health facilities poses hindrances during health service delivery and achievement of UHC. It was found that one of the major reasons for patient's dissatisfaction were out of pocket expenditure at private facilities and loss their daily wage to get access to the investigations. Problem-solving techniques were utilized to improve patient satisfaction and make the health system sensitive to the migrant urban poor population. The use of “plan do study act cycle (PDSA)“ technique for improvement of the health system with collaboration, advocacy, and feedback analysis with the government hospital helped improve health care access for the people with poor purchasing power. Feedback analysis of the established system helped in the sustainability and feasibility of the system for the smooth functioning of the referral system. Root cause analysis, health advocacy, and collaboration has helped making a model for improvement of access to health care services and patient satisfaction in an urban slum population. which maybe replication in a resource constraint setting.

Patient Safety/Quality Improvement Primer, Part II: Prevention of Harm Through Root Cause Analysis and Action (RCA2)

With increasing emphasis on patient safety/quality improvement, health care systems are mirroring industry in the implementation of root cause analysis (RCA) for the identification and mitigation of errors. RCA uses a team approach with emphasis on the system, as opposed to the individual, to accrue empirical data on what happened and why. While many otolaryngologists have a broad understanding of RCA, practical experience is often lacking. Part II of this patient safety/quality improvement primer investigates the manner in which RCA is utilized in the prevention of medical errors. Attention is given to identifying system errors, recording adverse events, and determining which events warrant RCA. The primer outlines steps necessary to conduct an effective RCA, with emphasis placed on actions that arise from the RCA process through the root cause analysis and action (or RCA²) rubric. In addition, the article provides strategies for the implementation of RCA into clinical practice and medical education.

Important Elements in the Quality Improvement Curriculum for Orthopaedic Residents

BACKGROUND

Orthopaedic residency education requires trainees to participate not only in clinical and research endeavors but also in quality improvement (QI) projects. To our knowledge, little has been published on how to implement a structured QI curriculum as part of an orthopaedic residency program. This article describes a single institution's experience with developing a longitudinal, integrated, and collaborative resident QI curriculum.

METHODS

The Six Sigma DMAIC (Define, Measure, Analyze, Improve, and Control) process was taught to residents as a formal curriculum at our institution beginning in 2014. A structured integrated process was developed for residents to work in teams and meet on a monthly basis. Since then, residents have developed multiple QI projects with measured outcomes. Serial surveys have been administered to the residents to collect feedback.

RESULTS

Seven major QI projects have been implemented by residents since the program's initiation. The resident surveys revealed significant improvement in comfort level with organizing QI projects. Residents also reported being comfortable working in interprofessional teams and incorporating patient safety techniques into clinical practice.

CONCLUSIONS

There are few guidelines that reflect how to initiate a formal QI curriculum in an orthopaedic residency program to promote a standardized and systematic way to approach QI projects. With a structured DMAIC education plan, an emphasis on graded responsibilities within a team setting, and responsiveness to resident feedback, orthopaedic programs can develop an effective QI program to allow residents to learn valuable patient safety practices, which allows residents to have a meaningful and impactful effect on QI initiatives that will serve them well as they enter clinical practice.

A National Survey of Quality Improvement Education in Physician Assistant Programs

PURPOSE

Quality improvement (QI) is emerging as a leadership and career track for physician assistants (PAs). Information on how PA programs teach QI is sparse. This study aimed to define how PA programs are providing education in QI through a national program survey.

METHODS

Curriculum survey questions were deployed as a part of the 2014-2015 Physician Assistant Education Association program survey. Questions were grouped into 4 categories: QI champion, pedagogy, integration strategy, and curriculum content. Differences between groups were analyzed, and logistic regression models were built to explore associations.

RESULTS

All 194 (100%) PA programs responded to the survey. There were 137 (70.6%) programs that were teaching QI. The median number of total instructional hours was 12 (interquartile range = 16, overall range = 109). There were 37 (27%) programs that were categorized as having a "mature curriculum." Mature curricula were significantly associated with a QI champion who is an expert from an outside department/institution (odds ratio [OR], 5.05; 95% confidence interval [CI], 1.14-22.33) and with programs that have a QI capstone or thesis project (OR, 3.66; 95% CI, 1.14-11.72) whose educational hours correlated more with experiential learning (r = 0.51, P < .01), small group sessions (r = 0.42, P = .01), and web-based modules (r = 0.36, P = .03).

CONCLUSION

Quality improvement is an important skill set for PAs, but nearly one-third of PA programs do not have a QI curriculum. Mature curricula were associated with more experiential learning and project-based learning (including capstone/thesis). This study captured many elements of QI education for PAs, which can be used by programs to develop and improve their curricula.