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Veterans Health Administration

First, Do No Harm

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The RCA process is key to VA patient safety efforts.

Taking a systems approach to problem solving

“We use it every day.”

Aartee Ignaczak is talking about a VA program that protects patients at VA medical facilities. It’s called the Patient Safety Information System.

Ignaczak is a program analyst with the VA’s National Center for Patient Safety, the office with the goal of reduction and prevention of inadvertent harm to patients as a result of their care.

One of the most important ways the VA does this is by conducting a Root Cause Analysis.

A Root Cause Analysis (RCA) is a critical part of the process of improving patient safety. RCA teams include members from several disciplines that investigate matters ranging from medication errors, to suicides, to wrong site surgeries.

The goal of the RCA process is to find out what happened, why it happened, and to determine what can be done to prevent it from happening again. Fundamental to VA’s patient safety efforts, it is used at facilities around the nation to develop a higher level of care for Veterans.

RCAs not only focus on actual adverse events, but on also close calls. Close calls are given the same level of scrutiny as adverse events that result in harm to a patient, as they occur anywhere from 3-to-300 times more often than actual adverse events. Close calls are events that could have resulted in a patient’s accident or injury, but didn’t — either by chance or timely intervention.

Focus on System Vulnerabilities

Another important aspect of the RCA process is that teams focus on system vulnerabilities, not individual performance. Individual performance is seldom the sole reason for an adverse event or close call. A previously unheeded or unnoticed chain of events most often leads to a recurring safety problem, regardless of the personnel involved.

People on the frontline are usually in the best position to identify issues and solutions. RCA teams at VA health care facilities include both clinical and administrative employees.

The teams improve patient safety at their facilities by formulating solutions, implementing them, and measuring the outcomes. To be truly effective, however, the RCA process must include extensive support from an organization’s leadership.

“Leadership involvement is critical to the RCA process and can occur at many different levels, often outside the executive suite,” said Mike Alexander, program analyst at VA’s National Center for Patient Safety (NCPS). “For example, senior staff members at one facility were photographed for a series of hand hygiene posters that were then placed all over the hospital.”

All RCA findings are entered into VA’s Patient Safety Information System. This confidential, non-punitive reporting system allows VA to electronically document patient safety information so lessons learned can be shared within a specific facility, or across the entire system, based on the nature of the event.

NCPS staff members manage the reporting system and also use it to examine the root causes of adverse events and close calls. For instance, over 60 percent of cases identify communication failure as a contributing factor in adverse events and close calls.

Aartee Ignaczak notes that the reporting system may be used, “to support requests for information from facility patient safety managers, as well as from other individuals within VA.” NCPS works with patient safety managers at 153 VA hospitals, and patient safety officers at VA’s 21 VA health care networks.

Data Help Identify Larger Issues

Since the Patient Safety Information System’s pilot test in 1999, almost 19,000 RCA reports and 800,000 safety reports have been entered. Using specialized software, it can be searched for trends and for a listing of specific events.

“The software we use allows us to drill down into the database and look for very specific information, such as medication names and equipment manufacturers,” said Ignaczak.

Continually reviewing RCA trends from the collected data helps develop VA patient safety initiatives. One example is the Medical Team Training program. This initiative was developed by NCPS to improve patient outcomes through more effective communication and teamwork among providers in critical care areas.

The National Center for Patient Safety was established in 1999 to lead VA’s patient safety efforts, but it also influences safety outside VA, where there is not the same requirement or motivation to report health care safety incidents. NCPS continues in its vital mission to develop — and nurture — a culture of health care safety for America’s Veterans.

Related link:
  Patient Safety
  VA’s Approach to Patient Safety