Root cause analysis for bloodstream infections
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1 Our vision: Healthier communities, Excellence in healthcare Our values: Teamwork, Honesty, Respect, Ethics, Excellence, Caring, Commitment, Courage Root cause analysis for bloodstream infections November 2015 John Ferguson, Director, Infection Prevention Service Hunter New England Health, NSW ACIPC 2015 Conference
2 Overview 1. RCAs and how they are done 2. Examples of two recent HNE RCAs 3. Observations about health system change imperatives 2
3 Pathology registrars Goroka physicians (R ) 3
4 Root cause analysis Formal method used to analyse serious adverse events (purposefully unsafe acts NOT in scope) Identify underlying problems that increase the likelihood of errors, taking the focus away from mistakes by individuals. Causal statements are generated through event mapping and investigation of links between context, events, actions and patient outcomes. Active and latent errors that contributed to or caused the event identified Ultimate goal learn from error/mistakes - prevent future patient harm by proposing system changes 4
5
6 RCA process (NSW/VA approach) Open disclosure Team chosen 3-4 (including JMO) ; team given qualified privilege Three team meetings; 90 day limit Meeting 1- Information gathering guided by checklists of questions; draft event flow diagram constructed; ask How, What, Why at each point; agree what further information required from whom Meeting 2- Review feedback; construct final flow diagram (check question at each point of the incident chain - So what ) ; construct cause and effect diagram Meeting 3- Define the real problem to be eliminated and define the most significant causes ask Why and work out contributing factors and potential root causes 6
7 Categories of RCA recommendations Communication Knowledge, skills and competence Work environment / scheduling Patient factors Equipment Policies / procedures Safety Mechanisms 7
8 Limitations of RCA RCA effectiveness in lowering risk or improving medical safety not systematically established Quality of RCA dependent on accuracy of input data as well as capability/experience of RCA team Relationships of team members are critical - trust, openness and honesty RCA is a reactive process that may overemphasise certain sources of error, ignoring a more complex reality Time and cost Shaqdan K, et al Root-cause analysis and health failure mode and effect analysis: two leading techniques in health care quality assessment. J Am Coll Radiol Jun; 11(6):
9 Mt Wilhelm, October
10 16 day-old male infant who developed a Pseudomonas aeruginosa BSI and died No root causes identified potable water suspected; System improvement opportunities identified: Ongoing weekly surveillance for pseudomonal colonisation Sterile water to be used when washing babies! Defrosting and warming bottled milk and EBM NOT under tap! Hot flushing of sinks regularly and flow straightener changes Further environmental testing if ongoing colonisation detected/ strain clonality demonstrated 10
11 11
12 Death of a 71 year old male from device - associated Staphylococcus aureus BSI One root cause: Lack of recognition of sepsis (clinical signs of sepsis, rapid response with lactate of 7.2) Three contributory factors: No follow up review of patient by treating team post rapid response and clinical handover omissions Problems with dosing, timing and choice of antibiotic therapy contributed Poor cannula management documentation of insertion & reviews Six system improvement opportunities! 12
13 Current HNE approach SAB events All events reported on to NSW incident monitoring system at SAC2 level 30 day death check using death registration data; captures out of hospital deaths (HNE ICNET database) Preventability checklist assessed by infection prevention template will be placed on RCAs commissioned for almost all events with mortality by 30 days (SAC1 events) and some other BSIs London protocol investigations other events local management led investigations 13
14 JHH Healthcare-associated S. aureus bloodstream infections
15 Port Moresby General Hospital 16
16 RCAs elephants in the room Lack of systems to hold staff (doctors) to account (not blaming) NB. pilot of Vanderbilt system in Oz 2016 (Cognitive Institute, QLD) Power and politics arrogance, bullying, passive aggression (not just medicos!) barriers to communication, escalation of issue or speaking up Silos infection prevention not everyone s priority Human factors not considered Patient disempowerment 17
17 Cf. ISO9000s management system - Q&S a result of good management 18 An even larger elephant Most hospital systems lack certain essential elements of consequential management; allows for lack of accountability, tolerance of process variation/ policy non-compliance Quality & Safety (including IPC) operates under a parallel infrastructure rather than being integrated
18 Perspective from James Reason : Human factors Situations and even systems are manageable if we are mindful. Human nature in the broadest sense is not. Most of the enduring solutions involve technical, procedural and organisational measures rather than purely psychological ones. Accountability Blaming people for their errors is emotionally satisfying but remedially useless. We should not, however, confuse blame with accountability. Everyone ought to be accountable for his or her errors [and] acknowledge the errors and strive to be mindful to avoid recurrence. 19
19 Thank you. 27
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