Finding root causes without blame helps eliminate errors

Initiative boosts staff support for improvement efforts

Searching for the root causes of adverse patient safety events under its new "nonpunitive environment policy" has helped Good Samaritan Hospital in Vincennes, IN, not only eliminate errors but also boost staff morale and engender staff support for improving performance.

The new policy has been in effect for approximately one year, notes Elaine Shaw, director of quality resources at the full-service facility.

"We started talking about it back in 2002. There was a lot of information out there about creating a safer environment for patients, and one of the possible strategies was to have a nonpunitive environment where employees did not feel threatened about addressing errors," she recalls.

Removing the blame factor

One significant obstacle to improved root-cause analysis, she observes, is a long history of blame-oriented investigations and tort actions that can cause individuals to be reluctant to share information about mistakes.

"We wanted to perform an investigation of an incident that would focus on real, fixable root causes rather than focusing on blame," Shaw explains.

The Good Samaritan Quality Council, which includes administration, medical staff, and Shaw (as facilitator), recommended the new policy to the board, which formally adopted it.

"When we updated our patient safety management plan for 2003, we put the wording in and officially implemented the policy," she says.

This was followed up by amnesty reporting, which stated, among other things, that if a staff member reported an error within 48 hours, no disciplinary action would be taken.

Investigating an incident

"The first incident we chose to investigate was one that, in the past, would probably have been very blame-oriented; a wrong patient was given the wrong drug intravenously," recalls Shaw. "This is a violation of our 5 Rights’ policy (right patient, right medication, right dose, right time, right route) that is standard practice throughout the medical industry."

The investigation was conducted using the TapRooT System®, created by Systems Improvement in Knoxville, TN. "TapRooT helped people focus on what happened and what could be done to improve performance, rather than focusing on who to blame," Shaw notes.

Actually, Good Samaritan had been using TapRooT since 1998 to conduct root-cause analyses for systems improvement.

"We liked the scientific approach," Shaw notes. "We were able to pick out causal effects, go through the process, and drill all the way down to the generic or root cause. It made the process clearer and allowed us to focus on what was important."

The system can be used either as software or manually. "When we train our people, we give them the manual paper pack, because if an incident has to be investigated [in another location] they can take it with them, and they have all the forms they need," Shaw explains.

"But they are also trained on how to use the software, which can only be accessed on their computer." TapRooT can be used not only for very serious events, but also to analyze processes staff want to improve, she adds.

"By using TapRooT, we found causes beyond the normal policy was violated’ causes that we had expected [in this first incident]," notes Shaw. The analysis found the following:

  • The IV bag design had changed, and now it was the same size as other bags.
  • The font and type used to label the bags was small and could easily be misread.
  • The nurses hurried because of unnecessary, repetitive paperwork that could be reduced to allow more time with patients and in administering medications.
  • The IV bags were being hung unnecessarily high, which made them hard to read for short nurses (especially if the nurse wore bifocals).

The increased information obtained led to a better understanding of the contributors to the errors and helped the investigation team develop corrective actions that previously would not have been considered. These included:

  • Increasing the type size that is printed on the label of the IV bags.
  • Putting the patient’s name in bold type to make it easier to find on the label.
  • Lowering the height of the bags for IVs being delivered by IV or PCA pumps.

"Implementing these corrective actions did not reduce the importance of the 5 Rights policy," Shaw explains. "The corrective actions actually highlighted the fact that hospital management was taking action to ensure that the 5 Rights policy could be implemented more effectively. This reinforces to our staff the importance of the policy and their compliance with it."

Impact on staff

The initiative had a positive effect on staff, says Shaw. "The people involved understood we were looking at processes and systems — not individual performance," she says.

"They felt freer, and they became as eager to solve this problem and find out why it occurred as management was. You had to be sitting in that room and see the light bulbs go on when we realized we had IV poles sitting where they did not need to be," Shaw points out.

Years ago, hospitals did not have IV pumps, and so they relied on gravity to produce the desired flow. "Today, however, if you have a nurse who is 5 feet tall, is in her 50s, and wears bifocals, they’d have a hard time reading the print on a bag that’s up in the air," she observes. "So there was a break in the system."

Staff attentiveness to the new policy did not occur by chance; the new message was driven home through targeted strategies. "It was accomplished mainly through continuing education. We made some poster boards, put story boards on the 5 Rights in areas where the staff would see them, and talked about it in staff meetings. We also made sure that in orientations sessions we placed enough emphasis on medication administration; we made a conscious effort to use that opportunity to drill home the importance of the 5 Rights," Shaw says.

As a result of the new policy, the following was accomplished:

  • Staff were more willing to openly share mistakes that they had made.
  • The investigation team identified causes they previously would have missed.
  • The hospital implemented corrective actions that will improve performance and improve compliance with a policy without blame or disciplinary action.

Another key to success, says Shaw, was that the nurses came to these decisions by themselves — that, for example, regardless of how busy they were, they should always follow the policy.

"They came up with that during an actual root-cause analysis," Shaw notes. "It made you feel good that it came from staff. We realized that we were dealing with human beings, and that errors do occur, but that it is the process that breaks down, not the employee."

She says the new policy has been successful. "There’s always been a little doubt, because for so many years in health care people have been used to blame being placed on an individual," Shaw notes. "In some ways, it’s easier for the new employees who hear about it during orientation; they do not have as hard a time with it as the older employees do. Still, behavior has started to become more accepting."

Her team recently conducted a survey, asking employees if they felt they could report error without fear of reprisal. "We got better scores than we anticipated," she reports.

The type of error studied in the first root-cause analysis has not occurred again.

[For more information, contact:

  • Elaine Shaw, Director of Quality Resources, Good Samaritan Hospital, Vincennes, IN. Phone: (812) 885-3331. E-mail:]