Imagine yourself in the middle of your rounds, and you note that one of your colleagues seems quite stressed about a patient. Despite their concerns being raised, nothing seems to be happening and the patient continues to deteriorate, and suddenly has a cardiac arrest. You become involved in trying to save the patient, helping where you can. Unfortunately, the patient cannot be resuscitated.
You are informed that you have been asked to be part of a Root Cause Analysis (RCA) team to investigate what went wrong.
Being asked to participate in an RCA can be anxiety provoking, but provides you with some unique opportunities to learn
As a junior doctor, you might initially feel anxiety about participating. But what if I told you this experience could become one of the most valuable lessons in your medical journey?
What is a Root Cause Analysis?
Let's start with the basics: what is a Root Cause Analysis. In healthcare, an RCA is a systematic approach used to identify the core causes of a problem or incident, without pointing fingers. The goal is to unravel what happened, why it happened, and more importantly, how to prevent it from happening again.
The process is protected by legal regulations* in Australia, ensuring openness and honesty in the discussion without fear of punitive consequences. The RCA process involves identification of the problem, data collection, cause analysis, solution identification, implementation, monitoring, and finally, report writing.
*Note - you should check the local legal protections and regulations regarding RCAs in your jurisdiction.
How an RCA works
The first step of an RCA is the identification of the problem or incident. This involves clearly defining the problem that occurred, which may require gathering detailed information about what happened, when and where it happened, who was involved, and what the immediate effects were. Understanding the incident at a granular level will form the basis of the subsequent steps of the RCA. Initially, this often involves constructing a timeline of events, in enough accurate detail as possible.
This phase involves asking lots of questions, in an effort to gather all the relevant information
Following the identification phase, data collection ensues. This could involve reviewing documents such as medical records, conducting or participating in interviews, observing processes, or using other methods that help gather comprehensive information about the incident. Collecting all relevant data enables a thorough analysis to take place in the next step. This phase is critical, as the quality of the data collected directly impacts the effectiveness of the RCA
The next phase is the cause analysis, which forms the core of the RCA process. This phase involves analysing the collected data to identify the underlying causes of the problem. As a junior doctor, you may contribute to this process using tools and techniques such as cause-and-effect diagrams, also known as fishbone diagrams or Ishikawa diagrams, the "5 Whys" technique, or fault tree analysis.
The "5 Whys" technique is an integral part of the cause analysis stage in a Root Cause Analysis (RCA). This technique is a simple but powerful tool that involves asking "Why?" five times to uncover the underlying or root cause of a problem or incident. The goal is to go beyond the surface-level symptoms and dig deeper into the issue at hand.
For example, if an adverse event occurred because a medication was administered incorrectly, the first "Why?" may reveal that the wrong dosage was given. Asking "Why?" again might disclose that the prescriber wrote an unclear order. Subsequent "Whys" could uncover systemic issues, such as lack of clarity in the prescription process or inadequate training for staff in reading prescriptions. This helps uncover the root causes of an incident, but also offer a practical demonstration of how complex healthcare systems can contribute to problems, and how small changes can potentially prevent future incidents.
This analysis phase aims to uncover not just the immediate causes of the problem, but the root causes. Identifying these root causes will then inform the next steps of identifying solutions, implementing them, and monitoring their effectiveness over time, all contributing towards preventing a recurrence of the incident.
An RCA is about understanding what went wrong, and how systems and teams can evolve to improve patient care.
The Role of Junior Doctors in a Root Cause Analysis
Now you might be thinking, what could I possibly add to this process?
Junior doctors can play a critical role in this process. You possess a unique perspective and direct knowledge of the incident which provides invaluable insights. Your role in the RCA ranges from providing detailed information, identifying contributing factors (and junior doctors can have an important perspective here), participating in analysis and solution development, to implementing and monitoring the proposed solutions. More importantly, your participation promotes a culture of safety within your organisation.
Protecting yourself
However, you might feel apprehensive about your involvement. Protecting your interests is key in such a scenario. Understanding the RCA process, seeking support if feeling stressed, being honest and open without admitting liability, documenting your actions and decisions, seeking advice from your medical indemnity provider or lawyer if necessary, and being willing to reflect and learn can help you navigate the situation smoothly.
What can junior doctors get out of the root cause analysis process?
The true beauty of being part of an RCA lies in the learning opportunities it presents. Here are some of the key lessons you could glean from the process:
Understanding Systems and Patient Safety Processes: Participating in an RCA provides a deep dive into the healthcare systems and processes. You gain a better understanding of how these systems interplay in patient care and how their failure can lead to adverse events.
This is a key benefit - participating will give you a broader understanding of how systems affect patient safety, and improve the safety culture within the organisation.
Deeper Understanding of the Clinical Issue: The RCA process encourages a thorough exploration of the clinical issue at hand. It allows you to understand the incident from multiple angles, enhancing your clinical acumen.
Develop Interpersonal Relationships and Manage Difficult Discussions: RCA involves interdisciplinary collaboration which can improve your communication and teamwork skills. It also teaches you to manage difficult conversations with empathy and professionalism.
Professional Responsibility: Participating in an RCA can be a vital step towards understanding your professional duties, including incident reporting, participating in investigations, and contributing to the improvement of patient safety.
Legal and Ethical Considerations: RCAs can provide insights into legal and ethical aspects of medical practice, such as informed consent, duty of care, and confidentiality.
Continuous Learning and Improvement: Finally, RCAs epitomise the essence of continuous learning and improvement in healthcare. It emphasises the importance of reflection, learning from errors, and persistent efforts towards enhancing patient care.
So much so, most CPD Home programs allow you to claim time for your participation in the RCA process.
Conclusion
Being part of an RCA can be a profound learning experience, contributing to both personal growth and professional development, and simultaneously count towards your CPD Home program. While it may seem daunting initially, it is a chance to actively participate in a process that aims to make healthcare safer for all. Embrace the opportunity with an open mind, a willingness to learn, and a steadfast commitment to patient safety, and you will find the experience rewarding. Remember, we are all learning, all the time. It's how we become better doctors.