TAKING ACTION ON ADVERSE EVENTS
The RCA process
By Sue Jones
The OmniCell medication dispensing units, Epic, order sets … these are just a few of the safeguards Shands has in place to prevent medication errors. However, errors can still occur. For example, within Epic the wrong look-alike medication could be selected – Oxycodone (immediate release) instead of Oxycontin (sustained release). A nurse might pull the right medication but become distracted briefly and administer the medication to the wrong patient.
When errors occur that resulted in, or could have resulted in a significant adverse outcome, Shands establishes an interdisciplinary team to conduct a Root Cause Analysis (RCA).
Participants in the RCA are those individuals (hospital staff and/or physicians) who were directly involved in the event. Additional key members of the team include the physician director of quality for that medical staff service, chief nursing office, chief medical office, quality director and unit manager.
Led by a RCA facilitator, the team develops a timeline of the event so that everyone understands exactly what happened and what was happening at the time of the event. From the timeline and their knowledge of the event, the team then identifies the root causes for the event, as well as other contributing factors. Examples of a root cause might be a medication label not matched against the patient’s armband, or a medication not matched against the patient’s medication administration record.
Once the team has agreed on the root and contributing causes, they then determine what process improvements need to be implemented to prevent the error from happening again.Members of the team are assigned to follow up on each of the team’s recommendations to make sure they are implemented and documented.
To assure continuity of the process improvements across the hospital, the results of each RCA are reported to the Shands at the University of Florida Board Quality Committee, the Patient Safety Quality Evaluation Committee and the UF&Shands Patient Safety Organization.