Root Cause Analysis and Healthcare

A root cause analysis is a way for healthcare facilities to examine what went wrong in a particular case and how to prevent the error from occurring again. The article, Techniques for Root Cause Analysis, published by Baylor University Medical Center in April 2001 considers the process entirely positive. Among the benefits is the ability to determine the frequency of particular errors or to identify the how often a specific part of the facility is involved.

Of particular importance, according to the article, is the participation of all the staff involved in the error. A different take on this has been suggested in Testing the Limits of Transparency in May 2008 by Patrice Spath who argues for the inclusion of not only staff involved in the incident but also patients and patients’ families.

Ms. Spath recounts the experience of parents who were asked to attend a root cause meeting by John Hopkins Hospital after their daughter died because of a medical error. Ultimately, the parents became involved with the hospital in corrective action. Some other facilities have since let down their guard and included families in root cause analysis but not without doubts.

Indeed, when confronted by the prospect of a widow’s involvement, one CEO reportedly was horrified, concerned about the liability risks. The process was found to be significant for identifying a problem, for allowing the family member to express her anger and emotions and explain a perspective that was not otherwise available.

Did it prevent a claim from being filed? The CEO did not know if that was the case and said that was not the intent. Rather “transparency was the right thing to do.”