When a significant patient care error occurs it is important to quickly gather all the pertinent facts and the full spectrum of causal factors when they are still fresh in everyone's memory. To acquire needed information, investigators should examine evidence collected from the scene of the event, witness statements, interviews, and documents. This inquiry should answer questions regarding "what," "when," "where," "who," and "how."

While each undesirable event does not need a formal root cause analysis, all reported incidents should be evaluated by the line manager or supervisor to identify the causes. What's important in an incident investigation is that physicians, managers and staff use a logical thought process to arrive at the most probable cause of the event. The following set of questions can be incorporated into your organization's root cause analysis model as guidelines for all problem inquiries.

Question #1: What really happened?
Quite often, the problem is mis-stated, obscured, or the real fault is disguised. By objectively describing the events leading up to the incident, you can be assured you're working on the right problem.

Question #2: What was the damage or consequence?
Once again, as in Question 1, the effects may be camouflaged. It is not unusual for the effect of a problem to be understated. If corrective actions are to be effective, it's important that everyone knows what is likely to happen if the problems are not fixed.

Question #3: What was different or changed?
By answering this question, the investigator may have insight into why the event happened, particularly with the first occurrence of a problem.

Question #4: What was the effect?
Studying the undesirable outcome of the problem may yield clues as to its real cause.

Question #5: What might have prevented the occurrence?
By asking this question, the investigator can identify processes and/or underlying systems that were less than adequate.

Question #6: What really went wrong?
This question is similar to Question 1, but the focus here is not on the what but the why.

Question #7: Did people do what they were supposed to do?
The answer here might be difficult to obtain if the organizational climate is not supportive, however the answers can point to problems in systems, training, performance appraisals, etc.

Question #8: Did any event/action prevent an even worse situation?
Answering this question will help the investigator to think through solutions to the problem as well as identify current problems in procedures, training, etc.

Question #9: Did people know what to do?
Somewhat like Question 7, the answer points to holes in present systems which prevent people from knowing what to do. Although staff can't be trained or procedures provided for every possible situation, determine what critical thinking skills were lacking and how they can be reinforced through coaching or education.

Question #10: Has this happened before?
Perhaps this should be the first question! The answer gives vital information regarding the nature of the problem as well as the efficacy of any previous corrective or preventive actions taken.

Question #11: If it happened before, what was done before to fix it, if anything?
If nothing was done, then it's time to do something NOW. If the previous solutions didn't work, then it's time to redesign corrective actions.

Question #12: Who reported this event?
Often this is important and may give clues as to problems with the reporting system itself. Was the person who reported the undesirable situation the one who should have first noticed it? If not, make sure to talk with the person who should have first noticed the event and find out why they didn't report it. The goal of this discussion is not to place blame, it's to find and resolve the underlying system issues that need correcting.

Question #13: What might prevent this event from happening again?
The answers to this question will help the investigator focus their attention on all possible corrective actions that might fix the problems. However, don't jump too quickly to the action planning phase. Wait until all root causes and solutions are identified and analyzed.  

Copyright 1998 Brown-Spath & Associates.

This article was excerpted from the book Investigating Sentinel Events: How to Find and Resolve Root Causes, published by Brown-Spath & Associates. For ordering information visit the Brown-Spath & Associates' web page at: http://www.brownspath.com

To Learn More: Patrice L. Spath is available for inhouse presentations on this topic and other healthcare quality subjects. She can be reached (503) 357-9185; email: Patrice@brownspath.com. Address comments or correspondence to: Brown-Spath & Associates, PO Box 721, Forest Grove, OR 97116.

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