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RCA TEAM SHOULD SHARE LESSONS LEARNED
By: Patrice L. Spath
Brown-Spath & Associates
| No sentinel event root cause
analysis (RCA) is complete without an evaluation step. This evaluation step should go
beyond just determining if the risk reduction strategies were successful. Judging the
effectiveness of the actions recommended by the RCA team is only part of the evaluation
step. The second part involves an evaluation of the sentinel event investigation itself.
The RCA team does this retrospective look at the entire root cause analysis so they can
pass along lessons learned to future teams. The RCA evaluation should be completed as the
last step before the team disbands. Ideally, the people on the team can discuss and
document their reactions to the process so that future RCA activities will be more
efficient. If these experiences are not recorded, lessons learned during the course of a
sentinel event investigation are typically lost and must be relearned by future groups. Develop a formal, written process for capturing the RCA team's evaluation comments. The RCA evaluation form is a useful communiqué of past successes and failures to pass along to newly formed teams. Include space on the evaluation form for the RCA team to document their answers to the following questions: 1. What went right? Why? 2. What went wrong? Why? 3. What contingency plans had to be implemented? Why? 4. What totally unexpected events impacted the RCA project? (Why were they unexpected? Could they have been anticipated? How could they be anticipated on future projects?) 5. How well did the RCA model used in this facility guide the project? (How could it have been better?) 6. What advice would you give to a group of people about to undertake a RCA? (What would you have done differently?) Root cause analysis teams spend considerable time investigating an undesirable patient incident and designing strategies to prevent future incidents. Don't lose the chance to learn from the team’s experiences. The valuable information obtained during a formal, written post-RCA evaluation process can help ensure the success of future RCA projects and enhance the patient safety efforts in your facility. Copyright 2001 by Brown-Spath & Associates
To Learn More: Patrice L. Spath is available for inhouse presentations on this and other health care quality and resource management topics. For further details, visit Brown-Spath & Associates on the web at: http://www.brownspath.com or write to: Brown-Spath & Associates, PO Box 721, Forest Grove, OR 97116. Visit the web site of Brown-Spath & Associates (www.brownspath.com) for the latest information on health care quality and resource management, free up-to-date articles on contemporary performance improvement topics and invaluable training resources. Our web site is updated at least quarterly, so be sure to return often!
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