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1
SAPPHIRE, Department of INTRODUCTION
Health Sciences, University of Box 1 Lessons not learnt
Leicester, Leicester, UK
Attempts to learn from high-risk indus-
2
John Walls Renal Unit, tries such as aviation and nuclear power
University Hospitals of Leicester, have been a prominent feature of the This example provides a summary of a real
Leicester, UK
3
CHILL, Nottingham University
patient safety movement since the late case that occurred in a hospital and the
Business School, University of 1990s. One noteworthy practice adopted failure to learn from the incident in spite
Nottingham, Nottingham, UK from such industries, endorsed by health- of a root cause analysis.
care systems worldwide for the investiga- In a large acute hospital, a patient
Correspondence to
Dr Mohammad Farhad Peerally,
tion of serious incidents,13 is root cause underwent a routine cataract surgeryan
SAPPHIRE, Department of analysis (RCA). Broadly understood as a operation with a minimal risk profileled
Health Sciences, University of method of structured risk identification by an experienced ophthalmologist. The
Leicester, Centre for Medicine
University Road Leicester, LE1
and management in the aftermath of wrong lens was inserted during the oper-
7RH UK; mfp6@le.ac.uk adverse events,1 RCA is not a single tech- ation. The error was promptly recognised
nique. Rather, it describes a range of postoperatively; the patient was returned
Accepted 20 May 2016
Published Online First
approaches and tools drawn from fields to the operating room and the procedure
23June2016 including human factors and safety was safely redone.
science4 5 that are used to establish how A subsequent root cause analysis identi-
and why an incident occurred in an fied that two lenses were in the operating
attempt to identify how it, and similar room, one (the wrong one) brought in by
problems, might be prevented from hap- an operating department assistant and the
pening again.6 In this article, we propose other by the surgeon. The investigation
that RCA does have potential value in report identified that having more than
healthcare, but it has been widely applied one lens in the operating room and a
without sufficient attention paid to what failure in the double-checking process had
makes it work in its contexts of origin, caused the incident. The action plan
and without adequate customisation for included the development of a new proto-
the specifics of healthcare.7 8 As a result, col emphasising the individual responsibil-
its potential has remained under-realised7 ity of the surgeon to select the appropriate
and the phenomenon of organisational lens, a training programme, improved
forgetting9 remains widespread (box 1). documentation and a poster emphasising
Here, we identify eight challenges facing the importance of double checks.
the usage of RCA in healthcare and offer One year later, in the same hospital, a
some proposals on how to improve learn- different patient with a different surgeon
ing from incidents. had the same procedure. Once again, the
wrong lens was implanted. This time, the
staff member who chose the wrong lens
The unhealthy quest for the root cause was the surgeon.
The first problem with RCA is its name.
http://dx.doi.org/10.1136/ By implyingeven inadvertentlythat a
bmjqs-2016-005991
http://dx.doi.org/10.1136/
single root cause (or a small number of
bmjqs-2016-006229 causes) can be found, the term root displaces more complex, and potentially
cause analysis promotes a flawed reduc- fruitful, accounts of multiple and inter-
tionist view.10 Incident investigation in acting contributions to how events really
the aftermath of an adverse event is unfold.7 1012 This is a tendency exacer-
intended to identify the latent and active bated by use of some RCA techniques
To cite: PeerallyMF, CarrS, factors contributing to the genesis of a (such as timelines or the five whys) that
WaringJ, et al. BMJ Qual Saf particular adverse event,4 but too often tend to favour a temporal narrative rather
2017;26:417422. results in a simple linear narrative that than a wider systems view.
similar and apparently more disparate incidents31 32 45 Implementation and evaluation of risk controls to elim-
and may also serve as a means of generating actions inate or minimise identified hazards need to become a
that require collaborative efforts between healthcare more visible feature of the RCA process.
organisations or indeed between industry and health- To maximise learning, lessons learnt from incidents,
care. Such an example could be for instance product descriptions of implemented risk controls and their effect-
redesigninga solution that may not be identified iveness need to be shared within and across organisations.
through the analysis of a single incident within one
department but may reveal itself as a recurring theme Twitter Follow Mohammad Peerally at @FP_Farhad
when analysing multiple incidents across many organi- Contributors MFP wrote the first draft of the manuscript,
sations. Linked to this, healthcare urgently needs to which was subsequently revised critically and edited by SC, JW
and MD-W. MD-W edited the final version of the manuscript.
develop and evaluate much better methods for design- All authors approved the final manuscript version being
ing risk controls and other improvement actions. One submitted for publication.
possibility that could be evaluated, for example, is Funding Wellcome Trust Senior Investigator Award (Mary
that of a hierarchy of risk controls.33 34 36 37 64 More Dixon-Woods (WT097899)) and Health Foundation
broadly, the use of active surveillance of issues that (Improvement Science Doctoral Awards).
have already been detected and monitoring of effect- Competing interests MD-W is the Deputy Editor-in-Chief of
BMJ Quality and Safety.
iveness of risk controls need to become a routine part
Provenance and peer review Not commissioned; externally
of the risk management process following RCAs. peer reviewed.
Healthcare also needs to markedly improve its cap-
Open Access This is an Open Access article distributed in
acity to evaluate, curate and share these risk controls. accordance with the Creative Commons Attribution Non
Such an approach would help to address the problem Commercial (CC BY-NC 4.0) license, which permits others to
that organisations tend to constantly reinvent risk con- distribute, remix, adapt, build upon this work non-
commercially, and license their derivative works on different
trols, resulting in waste and the creation of new terms, provided the original work is properly cited and the use
risks.58 An easily accessible database with descriptions is non-commercial. See: http://creativecommons.org/licenses/by-
of risk controls and contexts would enable lessons nc/4.0/
learnt from one RCA to be shared widely and support
a participatory approach65 to organisational learning.
Finally, healthcare needs to do more to detect REFERENCES
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BMJ Qual Saf 2017 26: 417-422 originally published online June 23, 2016
doi: 10.1136/bmjqs-2016-005511
These include:
References This article cites 47 articles, 11 of which you can access for free at:
http://qualitysafety.bmj.com/content/26/5/417#BIBL
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Notes