Root out causes of DP failures

How to apply accident investigation tools

By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

Case managers rarely are involved in adverse patient incidents, yet they can learn a lot about discharge planning failures by applying accident investigation tools. Accident investigation techniques can be helpful for evaluating why discharge planning didn’t go as expected.

One technique, change analysis, will assist case managers in determining what went wrong in a particularly difficult or challenging case. For example, why would discharge planning that is successful 99 times out of 100 fail to achieve expected goals one time? Change analysis examines planned or unplanned changes that caused undesired outcomes.

In an accident investigation, this technique is used to examine the mishap by analyzing the difference between what has occurred before or was expected and the actual sequence of events.

The investigators performing the change analysis identify specific differences between the accident-free situation and the accident scenario. These differences are evaluated to determine whether the differences caused or contributed to the accident. The origins of change analysis can be traced back to before World War II.

This change analysis technique can be applied to cases in which discharge planning failed to achieve desired goals. As its name implies, this technique emphasizes change. To determine what went wrong, case managers must look for deviations from the norm — those unanticipated things that happened and ended up affecting the outcomes. Change analysis is particularly useful for identifying obscure contributing causes of discharge planning failures that result from planned or unplanned changes in a system.

During the application of change analysis, case managers should identify changes as well as the results of those changes. The distinction is important, because identifying only the results of change may prevent you from identifying all the causal factors of the discharge planning failure. Ideally, change analysis is done as a team project with everyone in the case management department contributing their thoughts and expertise.

Here's how change analysis can be applied to a particular case: A 72-year-old male patient with a head injury is seen in the emergency department (ED). The treating physician rules out a subdural hematoma but wants to admit the patient to the hospital for short-term monitoring. The patient asks to be discharged home, saying he lives alone but will have his son come and stay with him. The physician agrees to the discharge but only after the patient confirms that he will have someone caring for him at home. Unbeknownst to the physician and the nursing staff, the patient has a history of confusion and doesn't know quite how to contact his son. After returning to his home via taxicab, the patient deteriorates. His neighbors find him 24 hours later in a semicomatose state. The patient is admitted to the hospital with a significant hematoma.

To use change analysis to evaluate what went wrong in this case, the first step is to describe the undesirable situation and then describe the same or similar situation that did not result in an undesirable outcome. The goal is to determine what was different when the undesirable outcome occurred. In other words, what disturbed the balance of the system that usually operates as planned?

Using a change analysis worksheet similar to the one shown by clicking here, the unintentional and unwanted changes are identified. To expand the case managers’ thinking about the causes of the failed discharge planning, the contributing factors are categorized into major elements that may have influenced the outcomes. In this example, the categories are: what, when, where, who, and how. These categories are useful in directing lines of inquiry and analysis. However, depending on the situation being investigated, other categories may be listed on the worksheet.

For each factor that is thought to influence the undesirable outcome, the team of case managers evaluating the event describes the "problem" situation relevant to that factor and the "ideal" situation. Issues that might be considered for each of the major factors are listed below:


  • What is the undesirable outcome?
  • What occurred to create the undesirable outcome?
  • What occurred prior to the discharge planning failure?
  • What occurred following the failure?
  • What operational activities were under way when steps leading up to the failure occurred?
  • What barriers should have been in place to prevent the undesirable outcome?
  • What barriers were in place but failed to stop the undesirable outcome?


  • When did the activities leading up to the discharge planning failure occur?
  • Was the facility on any special status at the time (e.g., emergency admission status)?
  • Did the time of day have an effect on the failure?
  • Did staff availability have an effect on the failure?


  • Where did the activities leading up to the event occur?
  • What were the physical conditions in the area(s)?
  • Where was the problem first identified?
  • Was location a factor in causing the event?


  • Who were the direct/indirect people involved caring for the patient?
  • Which case managers were assigned to the unit during the incident?
  • What were the training/qualifications of the case managers involved?
  • Who was coordinating the patient's care?


  • Was the discharge planning failure caused by an inappropriate case manager decision or action?
  • Did procedures exist for the patient care activities involved?
  • Did the procedures have sufficient detail to guide discharge planning decisions?
  • Did the procedure have sufficient fail-safe mechanisms?

Once the "problematic" situation and the "ideal" are described, evaluate the differences or variances to determine the effect of each factor on the undesirable outcome. In this example, analysis of the incident revealed that the case manager who covers the ED did not evaluate the patient because the incident occurred during shift change. In addition, the ED caregivers did not have access to the patient’s previous hospital records. Without these records, they didn’t have important information about the patient's past history of confusion.

The worksheet shows a partially completed change analysis containing information from this example to demonstrate the change analysis approach.

The worksheet allows the case managers to evaluate the differences between the "problematic" and "ideal" situation to determine each factor’s effect on the discharge planning failure. With a better understanding of the cause of the failure, the case managers now can work with the other involved departments to develop strategies for reducing the likelihood of future problems.