Why Are We Failing To Prevent Sentinel Events? By Mark Paradies
What kills more people in the US than industrial accidents, highway accidents, and airline accidents combined?
Mistakes in hospitals.
The technical term for these mistakes is “Sentinel Events.”
Estimates of the deaths caused vary. We use estimates because there are no accurate statistics on the total number of deaths caused by mistakes in hospitals. There is no national reporting requirement.
Even though there is no national reporting requirement, studies show that despite over a decade of effort to stop sentinel events, no progress is being made. Some studies actually show the problem getting worse. And this problem isn’t unique
WHY NO IMPROVEMENT
Why can’t we improve? There are a number of factors that make improvement difficult:
1. Healthcare Complexity
2. Poor Root Cause Analysis (RCA)
3. Inadequate Corrective Actions
4. Not Enough Management Attention
We will review all of these factors and what we can do about them in the following sections.
Medical practice keeps getting more complex. More complex technology. More drugs with more interactions. More pressure to work faster and be more efficient. The result? More chances to make errors with catastrophic consequences. At the same time, downsizing means less staff to catch errors.
Healthcare complexity calls for increased, proactive application of system reliability and human factors solutions to improve health¬care delivery. Intelligent, resilient design can make complex systems reliable. Plus, staffing needs to be assessed to ensure adequate coverage to apply error-catching activities.
POOR ROOT CAUSE ANALYSIS
After a decade of using RCA to analyze sentinel events, the lack of progress indicates a failure of healthcare root cause analysis.
What’s wrong? A majority of healthcare facilities use inadequate RCA systems including fishbone diagrams, 5-Whys, and healthcare derived root cause checklists. These “simple” techniques are inadequate to analyze complex healthcare sentinel events.
Not only are the RCA systems inadequate, the RCA training is also inadequate. People are assigned to investigate healthcare sentinel events with little or no training. They are lucky to attend a free one to eight hour session provided at a professional society meeting or sponsored by an insurance provider.
But healthcare investigators face another factor that makes root cause analysis even more difficult: BLAME. More than your everyday blame that comes with every accident. Medical malpractice seems designed to make people less open – less willing to cooperate wholeheartedly with investigators.
Furthermore, doctors who are independent contractors are naturally suspicious of investigators who seem to question their judgment and put their credentials at risk. Is it any wonder that we haven’t made progress?
Despite some of the factors that are difficult to address, picking an advanced root cause analysis system and getting people trained shouldn’t be hard. After all, there is TapRooT®!
The TapRooT® System was designed to be used for simple and complex investigations. It has been applied successfully in healthcare settings and has improved performance of complex systems. The 2-Day and 5-Day TapRooT® Courses have been customized for on-site training of healthcare investigators to help them with demanding investigations. Problems solved!
POOR CORRECTIVE ACTIONS
Inadequate root cause analysis is just the start. Typically, we see the weakest corrective actions applied to prevent repeat sentinel events.
Those familiar with the terminology “hierarchy of controls” applied in industrial and process safety may know what I am pointing out. Healthcare corrective actions often include the application of new standards that depend on human reliability. When these fail, investigators recommend some of the “re” corrective actions, including: re-train, re-mind, and re-emphasize (discipline).
But these are the weakest possible corrective actions (see pages 127 -129 in your 2008 TapRooT® Book.) More effective corrective actions include another type of “re” corrective action. Removing the hazard or the target. Or, re-engineering the process to improve system reliability and decrease human error without adding additional tasks for people to cope with.
These types of corrective actions and more are the result of a TapRooT® investigation when investigators apply the suggestions in the Corrective Action Helper® and apply Safeguards Analysis as part of the development of their solutions.
One might say that the cause of all the previous problems is inadequate management attention to performance improvement at healthcare facilities. Part of this inattention can probably be attributed to the fact that most healthcare administrators aren’t trained in advanced performance improvement techniques. Even the few who have had Six Sigma training don’t know about advanced root cause analysis and, therefore, don’t know about the action they could take to make performance improvement happen.
Plus, hospital administrators need to become more involved in the analysis, review, and approval of sentinel event investigations. Involvement can bring them face-to-face with the challenges people are experiencing in the field. Trained managers reviewing a SnapCharT® can see beyond blame to real action to improve performance. They can see their contribution to errors that come from understaffing and fatigue. They can become a knowledgeable part of the team fighting sentinel events.
SIMPLE PLAN TO IMPROVE
Each day, hundreds of lives are lost because we haven’t won the battle to defeat sentinel events. Don’t wait for the entire healthcare industry to wake up to the problems and solutions. Don’t wait for regulatory requirements to force your facility into action. Start today with the tools that are at hand.
1. Bring the message to management. Get them involved. They should feel that EVERY sentinel event at their facility is a personal failure to address the causes!
2. Adopt an advanced root cause analysis system – TapRooT® – including the latest root cause analysis software and database to help you learn from small incidents to prevent major sentinel events.
3. Get the training that your facility needs in root cause analysis. This includes training for hospital administrators, staff, and your performance improvement experts.
Start with a customized 2-Day TapRooT® Course for senior management. Follow that with a 2-Day TapRooT® Course for those who are frequently involved in sentinel event investigations and a 5-Day TapRooT® Course for those who facilitate sentinel event investigations.
4. Once you complete steps 1-3, you are ready to start continuous improvement efforts. Start by attending the TapRooT® Summit healthcare track to find out what other leaders in the field of healthcare are doing to continue improvement efforts.
Don’t wait. People are dying waiting for improvement to occur. Start today!
(Reprinted by permission from the February Root Cause Network™ Newsletter, Copyright © February, 2012)