Healthcare providers should revamp how they investigate medical mistakes. Instead of simply backtracking after a major incident, a root-cause analysis should carefully examine "near misses,” which are often ignored but could foreshadow potential problems, say guidelines released Tuesday (PDF) by the National Patient Safety Foundation.
Focusing on past harms rather than future risks is “a superficial and unsophisticated way to run a safety system,” says Dr. James Bagian, director of the Center for Healthcare Engineering and Patient Safety at the University of Michigan. He co-chairs a multidisciplinary panel of human factors, patient-safety and quality experts that issued the new NPSF recommendations.
Close calls occur regularly in healthcare, but in an event where a patient is not disabled or killed, “Most institutions don't do anything to formally understand and mitigate the risk to future patients,” Bagian said. “That's a wasted opportunity and a large part of the problem.”
The Institute of Medicine called attention in 1999 to an epidemic of medical errors when it released To Err is Human, a report which estimated as many as 98,000 patients die from preventable events each year in U.S. hospitals. Despite a more than 15-year effort by policymakers and healthcare providers to reduce the incidents, safety leaders say there remains a long way to go to cross the quality chasm.
The lack of progress has led some to call for more aggressive regulatory action, including the healthcare equivalent of the Federal Aviation Administration, which could both set and enforce rules.
Others have encouraged learning from fields like engineering and considering all the things that could possibly go wrong with a new process, tool or system before it is launched.
Being able to identify learning opportunities from near misses before a patient suffers major harm is a main focus of the new 41-page NPSF report entitled RCA²: Improving Root Cause Analyses and Actions to Prevent Harm (PDF).
The recommendations are intended to help healthcare providers rethink the way mistakes are identified, assess which types of events are most appropriate for analysis and determine the proper actions to take following an evaluation. “Analysis alone doesn't fix anything. It's only the first step,” Bagian says. The report organizes corrective actions into a hierarchy. “If you don't take action, the rest is a waste of time.”
The NPSF will host a free webinar at 1 p.m. on July 15 to discuss the new guidelines. The new report is part of a broader push from the group to reboot the patient-safety movement by evaluating lessons learned over the past decade and seeking new opportunities to advance the field.