Since the beginning of time, it seems, we have educated our staff on the importance of root cause analysis (RCA). RCA is mainly used to identify “why” something happened, including falls, sepsis, elopements, etc. Our QAPI committees meet quarterly (or more often, hopefully) and discuss the “5 whys”, we “peel back the onion”, we use the fishbone diagram, but no matter which method your team uses it is still the process of RCA.
As healthcare providers we use the RCA on a regular basis, however, sometimes we still get “stuck in the mud” and we just aren’t able to identify the RCA for a specific outcome. This can be frustrating however it is still a valuable process that leads to improved safety for our residents! In an article published in AHRQ PSNet, a systematic review evaluated whether interventions implemented based on RCA outcomes were effective at preventing similar adverse events in Veterans Health Affairs (VA) settings. All 10 of the studies included in the review reported improved outcomes following RCA-recommended interventions.
As with all studies, there are caveats, and it is suggested that future research emphasize quantitative patient-related outcome measures to demonstrate the impact and value of RCAs. At the end of the day, we are right on target, sure we will have a hiccup here or there but stay the course! The research proves that although it might be a difficult task at times, our resident’s safety should continue to be the focus! Gather your team, talk about the residents at risk, and get the ball rolling on “why”! Stay the course, stay informed, and stay well!