Patient safety Patient care as a healthcare discipline emphasizes highly on the analysis, reporting, and prevention of any medical error that may lead to adverse healthcare situations. There are many avoidable medical errors which have for a long time impacted in many patients. Patient safety as a discipline tries to address the issue in order to reduce or prevent the massive numbers of patients killed or harmed in medical errors (Vincent, 2010).
It is said, To Err Is Human, but as per the simplest definition of health care error which says that health care error is a form of preventable adverse effect of care, it is clear that most of these errors are due to human factors, which are avoidable.
Patient safety is, without doubt, a fundamental principle in the field of health care. There is a certain degree of risk in every point in the care giving process (Galt & Paschal, 2011). Patient safety demands a complex system that involves distinct actions in improvement of performance, environmental safety, and risk management which with it involves safe use of medicine, safe clinical practice, and infection control and above all a safe environment of care (Fagerhaugh & et, 1987).
The rise in concerns about patient safety has triggered a series of policy responses. Many reports have argued that changes in systems and cultures are vital to improve on patient safety. Root cause analysis (RCA) as a procedure for identifying the reasons behind adverse events and is highly recommended. This help people answer questions about why the problem occurred before indulging to treatment (Latino & Latino, 1999).
Root Cause Analysis identifies the origin of the problem by use of specific steps and associated tools in the determination of what happened, why it happened and figuring out immediately what to do to minimize the instances of the problem arising again. This technique assumes that system and events are interrelated, thus an action in a certain area triggers another. This means tracing the actions increases the chances of discovering where the problem started and how it grew to symptoms experienced (Wu, Lipzhutz, & Pronovost, 2008).
RCA seeks to determine the origin of a problem. The analysis makes an assumption that events and systems are usually interrelated. This is to mean that an action in a given area triggers an action in another area and the process repeats itself. The origin of the symptoms being experienced can be discovered by tracing back these actions. There are essentially three causes of errors, be they medical errors or otherwise. These causes are physical (failure of material items); human causes (human failures) and lastly organizational causes in the sense that, a system, policy or process that is used is faulty (Berntsen, 2004).
Through the use of RCA, a revelation of more than one cause can be made as the process identifies all the above causes. It involves investigation of the patterns of negative effects, finding hidden defects in the system and discovery of specific acts that contributed to the occurrence of the problem. Even though there might be a need for a change of systems after RCA, impact analysis is another particularly helpful tool. It helps to determine any possible negative or positive consequences of a change on any part of the system (Hitchings, Davies-Hathen, Capuano, Morgan, & Bendekovits, 2008).
It is, however, very difficult to determine which situations or cases qualify for root cause analysis. Some repetitive situations are distributed over time that one may not even realize they are recurring, or else, they happen to different people that they recurring nature is not known. These among other reasons make it difficult to determine where to partake RCA.
Root cause analysis is a valuable tool in health care organizations. As a tool, it should be learned by all personnel as it can be used at several levels.