CPSI, Root Cause Analysis Workbook - Paediatric Chairs of Canada

30The following causal statements have been developed forthe sample case used in this framework.1. Look-alike/sound-alike medication names increasedthe likelihood that a nurse would select andadminister Hydromorphone instead of Morphineas intended.2. The removal of drug identification information fromthe Hydromorphone package to facilitate narcoticcounts increased the likelihood of a look-alikemedication being selected.3. The routine availability of a high potency, yetinfrequently used narcotic in the emergencydepartment increased the likelihood of an incorrectdrug selection.Develop ActionsThe ultimate goal of an RCA is the development ofactions to reduce the potential for recurrence of a similarevent. The team will identify measures to address theroot causes they have uncovered. The initial focus ison removal or elimination of the circumstances thatallowed the outcome. If there is no action that can beapplied to eliminate the cause, the team should seekthe most appropriate control to reduce the possibilityof recurrence. It is important to note that applying acontrol means that although checks will be in place,there still is a chance of reproducing the same or relatedcircumstances that led to the original critical incident.There are circumstances under which a team maychoose to accept one or more root causes withoutfurther intervention. The frequency and/or severityof the incidents may not be significant. The team maydetermine that one or more root causes cannot be altered,thus they must be accepted. For example, in reviewing anevent related to lack of timely access to tertiary care, theRCA team would have to accept the fact that this level ofservice will not be made available in remote locations andfocus attention on rapid transfer of patients when suchservices are needed.When recommending change, many possible categoriesof options with varying degrees of effectiveness,ranging from most to least effective, are available. Theteam should be apprised of this range of possibilities(see below, listed in order from most effective to leasteffective) and encouraged to recommend the mosteffective solution that is reasonable and/or possible giventhe circumstances. Note that items such as training andpolicy development are necessary components, but do notchange the underlying conditions that lead to error.Recommended Hierarchy of Actions: 38Stronger Actions• Architectural/physical plant changes• New device with usability testing before purchasing• Engineering control or interlock (forcing functions)• Simplify the process and remove unnecessary steps• Standardize on equipment or process or caremaps• Tangible involvement and action by leadership insupport of patient safetyIntermediate Actions• Increase in staffing/decrease in workload• Software enhancements/modifications• Eliminate/reduce distractions (sterile medicalenvironment)• Checklist/cognitive aid• Eliminate look and sound alikes• Read back• Enhanced documentation/communication• RedundancyWeaker Actions• Double checks• Warnings and labels• New procedure/memorandum/policy• Training• Additional study/analysisActions should:• target the elimination of the root causes;• offer a long term solution to the problem;• have a greater positive than negative impact on otherprocesses, resources and schedules;• be objective and measurable; and• be achievable and reasonable.From a human factors standpoint, the strongestinterventions are “physical rather than proceduraland permanent rather than temporary.” 53 Examples ofpreferable actions include architectural or physicalchanges and forcing functions. An example of anarchitectural change would be installation of grab bars;a forcing function example would be lack of connectivityof non-related devices, for example blood pressure cuffsand luer lock syringes. Standardization of processes andequipment (for example, limiting the number and type of53Caryl Lee and Kierston Howard Hirschler, “How to Make the Most of Actions and Outcome Measures,” NCPS TIPS July/August (2004), (accessed November 28, 2005).