How would you ensure that the RCA is detailed and provides i

How would you ensure that the RCA is detailed and provides insight into the contributory issues of medical errors?

Solution

RCA or root cause analysis is a systematic approach to identify problems or adverse events and analyse them. This helps them understand the root cause and take necessary actions to prevent future occurrence of such unwanted events.

A medical error can occur at any stage of patient care like diagnosis, treatment or preventative care. Medical errors primarily due to 2 reasons-either the approach of treatment is wrong or the treatment is not executed properly.

The RCA needs to be comprehensive and watertight to identify the problems clearly.

The RCA needs to find which departments were involved in the decision making, The missing and weak steps in the process, their reasons along with their rectifications.

It needs to be clearly stated whether it was a human error, if yes then has the mistake been addressed and rectified.

Was the staffing appropriate to address the issue and will in-house orientation and staff training improve the situation.

Whether there were any unexpected events that occurred and whether all the necessary information available at that time. Is the communication adequate and if there are any equipment failures. Was The physical environment favourable and are the systems in place to identify the problems.

The root cause analysis would be the one in which the participants identify the risk points and their potential contribution to the event.