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Using Apparent Cause Analysis to Improve Safety and Quality
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QUALITY organizations are reliable: they understand why things go wrong, figure out how to prevent it and deal with problems, and bounce back quickly and safely.
Using Apparent Cause Analysis
to Improve Safety and Quality
What are the core roles of the HSO?
SAFETY and QUALITY
Incident reporting: a graded approach
ACA (Apparent Cause Analysis)
Mild severity:
SQIS
Effective Cause Analysts need to understand:
- why PEOPLE make errors
- why PROCESSES/SYSTEMS fail
- why EQUIPMENT fails
- why EXECUTIVE DECISION MAKING fails
Moderate severity:
ACA
ACA Training for Housestaff Safety Officers
Why does QUALITY matter?
How does it relate to RELIABILITY?
High severity:
RCA
Example: An ICU pt was transferred to the floor; later that night a rapid response called for hypoxic respiratory distress. Failed on BiPAP and airway code called. Pt was intubated and transferred to ICU. In ICU it was discovered that pt was actually made DNR/DNI a few days earlier, and would not have wanted intubation at all.
Example: Concentration of Dopamine drip is changed hospital wide. A week later, an ICU pt is placed on a dopamine drip and noted to be hypertensive/tachycardic. Night shift nurse notices incorrectly programmed pump.
Building a culture of safety and reliability via the use of Apparent Cause Analysis (ACA)
Changing Culture
Patrick Wu, PGY4
UCI Department of Anesthesiology and Perioperative care
pwu@uci.edu
Culture changes lead to behavior changes...
How is the QUALITY of healthcare?
HSO's should be
Quality/safety champions!
SQIS:
Incident reporting
98k deaths per year due to medical ERRORS
2 747's a week!!