Root-cause analysis vital to sentinel event policy

You should ask Why?, then Why? again

At the heart of the new sentinel event policy is the root-cause analysis (RCA), and to remain compliant you must understand the concept. The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, defines an RCA as a process for identifying the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event. RCAs, according to the Joint Commission:

• focus primarily on systems and processes, not individual performance;

• progress from special causes in clinical processes to common causes in organizational processes;

• repeatedly dig deeper by asking Why?, then Why? again;

• identify changes that could be made in systems and processes — either through redesign or development of new systems or processes — that would reduce the risk of such events occurring in the future.

RCAs are essential to any ongoing operation, even those outside health care. "The only thing that changes is the vocabulary and the political cultures," says Robert J. Latino, vice president of strategic development for Reliability Center, an engineering consulting firm in Hopewell, VA. Though Latino’s firm specializes in continuous process industries such as oil refining, steel, aluminum, and chemicals, he sees similarities to the health care industry.

Aside from the fact that the Joint Commission requires RCAs, if you don’t perform formal analyses and act on them, you run the risk of recurrence of sentinel events. In addition to documenting various causes, they show an attempt on your part to identify the true causes of a failure to prevent recurrence. "Our [RCA] method forces users to identify three levels of cause: physical, human, and latent."

A physical root could be that the wrong medicine was given to a patient. The human root is that a conscious decision was made by the person administering the medicine to do so. The latent roots (organizational roots) would be the reason the person made the decision to administer the medicine — maybe the staffer was trained not to question a doctor’s orders, or the text on the medicine label was not legible, or the wrong medicine was in the bottle. If you don’t uncover the latent roots, you open yourself up to more risk by increasing the odds of recurrence.