Authors (including presenting author) :
Kwok YTA(1)(2), Mah AP(1)(3), Pang MCK(1)(3)
Affiliation :
(1)Workgroup on Root Cause Analysis Review, Hospital Authority (2)Quality and Safety Division, New Territories West Cluster (3)Quality and Safety Division, Head Office, Hospital Authority
Introduction :
At Hospital Authority (HA), sentinel events (SEs) are mandatory reporting incidents since 2007 and serious untoward events (SUEs) are also mandated for reporting in 2010. For all SEs and SUEs, root cause analysis (RCA) has to be conducted to investigate the root causes and identify improvement actions. There has been doubts in HA that RCAs are not effective in enhancing patient safety by eliminating the risks, however, no evaluation on the effectiveness of RCA has ever been conducted.
Objectives :
(1)To evaluate the effectiveness of RCA in HA. (2)To propose possible ways to enhance the effectiveness of RCA in the HA.
Methodology :
A retrospective study of SE and SUE RCA reports conducted from October 2016 to September 2018 in the HA was undertaken. The incident nature, types of root causes and strengths of recommendations were analysed by an RCA Reports Review Team. The Review Team comprised of 3 reviewers to conduct an independent review.
Result & Outcome :
Total 214 HA RCA reports (62 SEs and 152 SUEs) were reviewed. These RCA reports generated 504 root causes (average 2.4 per report) and 658 recommendations (average 3.1 per report). The most common types of root causes was "Task - Non-adherence to policy/guideline" (152, 30%), "Education and Training" (87, 17%) and "Staff" (81, 16%). These results showed that the root causes might only have focused on the proximal factors and might not have investigated the organisational/system factors. For recommendations, 18 (3%) , 116 (15%) and 626 (82%) of them had strong, medium and weak strengths respectively. The high proportion of weak recommendations might indicate that low effectiveness of RCA in the past. In regard to the results, the Review Team suggests conducting RCA training with human factors concepts and implementing easy-to-use RCA tools to enhance the RCA effectiveness in the future.
