A colleague recently shared an article that caught my attention…and triggered several take-aways. Medical Malpractice Claims: Pivotal Role of Root Cause Analysis was published by the Joint Commission, a U.S.-based nonprofit that accredits more than 22,000 domestic and foreign health care organizations and programs.
In this case, the Joint Commission reported its review of “over 14,000 serious medical errors that resulted in significant patient harm or death. Individual healthcare organizations that report these specific medical mistakes, known as Sentinel Events, are expected to perform a “Root Cause Analysis” (RCA) – an investigative process which seeks to determine the specific and, often underlying system flaws or process errors, that caused the event.”
As a nurse with lots of clinical experience, I know that hospitals often conduct an RCA whenever an event results in an unanticipated outcome or if the event has the potential for a serious adverse outcome. With that perspective — along with 30 years of claims experience as a Legal Nurse Consultant — here are some of my top take-ways from the Joint Commission’s report on Root Cause Analysis:
- Identify the fundamental cause of the error
- Is the error active or latent?
- Is there more than one root cause leading to the error?
- Develop targeted and manageable protocols and solutions
- Improved processes can prevent errors
MKC encounters process errors in a variety of other contexts. For example, we are often involved in medical malpractice claims that have process errors as a component as well as cases involving errors related to dispensing prescribed meds.