Root Cause Analysis of a Death at an Australian Hospital
Brief Summary from the Press
A video of the initial news…
The woman died of a heart attack after waiting for hours in an ambulance to be admitted to the Busselton Hospital. This practice, called ramping, seems common from reports in the Australian press.
Here is an audible report about “ramping:” Click HERE for Audio Report.
Will the Root Cause Analysis Be Thorough and Credible?
Why do I ask this question? Because so many healthcare root cause analyses are superficial and don’t produce permanent performance improvement.
Healthcare RCAs often use substandard techniques like 5-Whys, Fishbone Diagrams, or fairly simple checklists that don’t help investigators go beyond their current knowledge when investigating “Critical Incidents” (as they are called in Australia) or Sentinel Events (as they are called in the USA) and don’t develop effective corrective actions.
Problems in the healthcare system in Australia are not new. Three years ago I wrote an article titled:
It showed statistics from Australia (2007) that the odds of an adverse event when visiting an Australian hospital was 16.6%. That’s about the same (1 in 6) as playing Russian Roulette.
If advanced root cause analysis (based on the root cause analysis fundamentals) was being used and effective corrective actions were being implemented, how much improvement should we expect in 15 years?