Team experiences of the root cause analysis process after a sentinel event: a qualitative case study.
Childbirth
Norway
Organizational learning
Qualitative case study
Root cause analysis
Sentinel events
Journal
BMC health services research
ISSN: 1472-6963
Titre abrégé: BMC Health Serv Res
Pays: England
ID NLM: 101088677
Informations de publication
Date de publication:
08 Nov 2023
08 Nov 2023
Historique:
received:
21
06
2023
accepted:
18
10
2023
medline:
10
11
2023
pubmed:
9
11
2023
entrez:
8
11
2023
Statut:
epublish
Résumé
Root cause analysis (RCA) is a systematic approach, typically involving several stages, used in healthcare to identify the underlying causes of a medical error or sentinel event. This study focuses on how members of a Norwegian RCA team experience aspects of an RCA process and whether it complies with the Norwegian RCA method. Based on a sentinel event in which a child died unexpectedly during childbirth in a Norwegian hospital in 2021, the following research questions are addressed: 1. What was the RCA team's experience of the RCA process? 2. Was there compliance with the Norwegian RCA method in this case? A case study was chosen out of the desire to understand complex social phenomena and to allow in-depth focus on a case. The result covered three main themes. The first theme related to the hospital's management system and aspects of the case that made it challenging to follow all recommendations in the Norwegian RCA guidelines. The second theme encompassed external and internal assessment. The RCA team was composed of members with methodological and medical expertise. However, the police's involvement in the case made it complex for the team to carry out the process. The third and final theme covered intrapersonal challenges RCA team members faced. Team members experienced various challenges during the RCA process, including being neutral, dealing with role-related challenges, grappling with ambivalence, and managing the additional time burden and resource constraints. As anticipated in the RCA guidelines, the team's ability to remain neutral was tested. The findings of this study can help stakeholders better comprehend how an inter-professional RCA teamwork intervention can affect a healthcare organization and enhance the teamwork experience of healthcare staff while facilitating improvements in work processes and patient safety. Additionally, these results can guide stakeholders in creating, executing, utilizing, and educating others about RCA processes.
Sections du résumé
BACKGROUND
BACKGROUND
Root cause analysis (RCA) is a systematic approach, typically involving several stages, used in healthcare to identify the underlying causes of a medical error or sentinel event. This study focuses on how members of a Norwegian RCA team experience aspects of an RCA process and whether it complies with the Norwegian RCA method.
METHOD
METHODS
Based on a sentinel event in which a child died unexpectedly during childbirth in a Norwegian hospital in 2021, the following research questions are addressed: 1. What was the RCA team's experience of the RCA process? 2. Was there compliance with the Norwegian RCA method in this case? A case study was chosen out of the desire to understand complex social phenomena and to allow in-depth focus on a case.
RESULTS
RESULTS
The result covered three main themes. The first theme related to the hospital's management system and aspects of the case that made it challenging to follow all recommendations in the Norwegian RCA guidelines. The second theme encompassed external and internal assessment. The RCA team was composed of members with methodological and medical expertise. However, the police's involvement in the case made it complex for the team to carry out the process. The third and final theme covered intrapersonal challenges RCA team members faced. Team members experienced various challenges during the RCA process, including being neutral, dealing with role-related challenges, grappling with ambivalence, and managing the additional time burden and resource constraints. As anticipated in the RCA guidelines, the team's ability to remain neutral was tested.
CONCLUSION
CONCLUSIONS
The findings of this study can help stakeholders better comprehend how an inter-professional RCA teamwork intervention can affect a healthcare organization and enhance the teamwork experience of healthcare staff while facilitating improvements in work processes and patient safety. Additionally, these results can guide stakeholders in creating, executing, utilizing, and educating others about RCA processes.
Identifiants
pubmed: 37940969
doi: 10.1186/s12913-023-10178-3
pii: 10.1186/s12913-023-10178-3
pmc: PMC10634119
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
1224Informations de copyright
© 2023. The Author(s).
Références
Jt Comm J Qual Patient Saf. 2008 Jul;34(7):391-8
pubmed: 18677870
BMJ. 2000 Mar 18;320(7237):726-7
pubmed: 10720336
Qual Saf Health Care. 2008 Feb;17(1):37-46
pubmed: 18245218
J Healthc Risk Manag. 2021 Jul;41(1):31-46
pubmed: 33340179
PLoS One. 2018 Jul 26;13(7):e0201067
pubmed: 30048491
BMC Med Res Methodol. 2013 Apr 08;13:55
pubmed: 23566017
J Diabetes Metab Disord. 2016 Jul 28;15:27
pubmed: 27471680
JAMA. 2008 Feb 13;299(6):685-7
pubmed: 18270357
Am J Med Qual. 2010 May-Jun;25(3):186-91
pubmed: 20460564
BMJ Qual Saf. 2017 May;26(5):381-387
pubmed: 27940638
BMC Health Serv Res. 2020 Jun 5;20(1):507
pubmed: 32503514
Indian J Public Health. 2013 Jul-Sep;57(3):138-43
pubmed: 24125927
BMJ Open. 2020 Dec 3;10(12):e042847
pubmed: 33273051
Jt Comm J Qual Patient Saf. 2015 Nov;41(11):494-501
pubmed: 26484681
Am J Infect Control. 2015 May 1;43(5):499-505
pubmed: 25798774
Qual Res. 2015 Oct;15(5):616-632
pubmed: 26457066
Med Princ Pract. 2020;29(6):524-531
pubmed: 32417837
J Healthc Risk Manag. 2015 Sep;35(2):21-30
pubmed: 26418137
BMJ Qual Saf. 2017 May;26(5):417-422
pubmed: 27340202
JAMA Ophthalmol. 2015 Jun;133(6):631-2
pubmed: 25742139
Qual Saf Health Care. 2006 Dec;15(6):393-9
pubmed: 17142585
BMJ. 2000 Mar 18;320(7237):768-70
pubmed: 10720363
Int J Qual Health Care. 2015 Oct;27(5):418-20
pubmed: 26294709
Soc Sci Med. 2011 Jul;73(2):217-25
pubmed: 21683494
Am J Med Qual. 2014 May-Jun;29(3):181-90
pubmed: 23814026
Patient Saf Surg. 2016 Sep 21;10:20
pubmed: 27688807
J Paediatr Child Health. 2019 Sep;55(9):1070-1076
pubmed: 30582234
Stud Health Technol Inform. 2016;226:131-4
pubmed: 27350485
J Health Serv Res Policy. 2011 Apr;16 Suppl 1:34-41
pubmed: 21460348
Nurs Manag (Harrow). 2017 Jun 29;24(4):28-33
pubmed: 28659071
BMC Health Serv Res. 2013 Feb 07;13:50
pubmed: 23391260