Patient safety continues to be a concern for health care institutions and the general public.1 James2 estimated that 210 000 hospital deaths per year were associated with preventable harm. The findings from that study indicated that deaths associated with medical errors occur far too often. The large number of preventable deaths also supports the need for health care professionals to understand methods to analyze errors to prevent them from recurring in the future. One widely used process to examine medical errors is root cause analysis (RCA).
Although participating in the process of conducting an RCA is an important experience for nursing students, the opportunity to participate in the actual process in a clinical facility is minimal if at all. Lack of opportunities can be attributed to concerns with confidentiality of information and discovery potential. As a result, nurse educators should be prepared to identify and use other methods for students to gain this experience. There are few examples in the nursing literature for best practice teaching for the process of RCA; only 2 articles were found. Lambton and Mahlmeister3 suggested 2 methods of teaching RCA to nursing students, a mock RCA after an error in the clinical setting and a simulated RCA. Harrison4 proposed using the skills laboratory to engage students in a mock RCA using faculty-created sentinel event scenarios.
In this article, we describe our approach to engage nursing students in the RCA process using problem-based learning (PBL) within a senior leadership and management course. Students conduct a mock RCA based on an actual medical error reported either in the media or scholarly literature. The cases used for the RCA are selected by the students based on their particular area of interest.
Background
Root cause analysis is a commonly used, structured approach to analyze adverse events.5 The process may examine both active (at point of interface between human and system) and latent medical errors (hidden system problems contributing to adverse events).6 Those who conduct an RCA search for the what, how, and why a particular adverse event has occurred.7 An RCA provides answers to 5 key questions: What happened? When did it happen? Who is involved? How did it happen? Why did it happen?8 By examining the entire system involved with and leading up to an error, an RCA allows for attribution of error to system variables, such as work flow processes and flaws such as equipment failure, rather than blaming individual parties.9 The process of RCA dispels the culture of blame (blaming a person) and fosters a just culture (investigating the process).
Implications for Nursing Education
According to one of the Essentials of Baccalaureate Education for Professional Nursing Practice, Basic Organizational and Systems Leadership for Quality Care and Patient Safety, programs should prepare graduates to apply quality improvement principles to effectively implement patient safety initiatives and monitor performance measures.10 One suggested area of sample content under this essential is an overview of quality improvement process techniques, including RCA.10 The need for programs to prepare graduates who can effectively participate in the process of RCA places particular demands on both programs and faculty. Nursing programs need to allocate time and resources to support student learning and develop faculty with expertise in quality improvement processes such as RCA. Faculty need to recognize the urgency to cultivate a culture that values quality improvement processes and align the nursing curriculum to meet this important goal.11,12
In addition to the Essentials, the Quality and Safety Education for Nurses (QSEN) initiative resulted in competency statements and recommendations that specifically address patient safety and identify the opportunity to participate in an RCA as an educational activity.13 Two QSEN competencies, quality improvement and safety, relate to the knowledge and skills pertaining to RCA. To meet those competencies, students should be able demonstrate knowledge of quality and safety by describing processes to analyze errors and participate in an RCA of a sentinel event.13
Furthermore, the process of RCA is congruent with interprofessional care. Nursing education leaders recognize the importance of teaching students to value the interprofessional component in providing safe, competent, quality care.14 Conducting a RCA requires a comprehensive and collaborative team approach to examine the particular system, identify areas of breakdown contributing to the error, and develop strategies and actions to prevent a recurrence of that error. For the RCA to be interprofessional in nature, it should include members of the disciplines involved with the system in which the error occurred.
Problem-Based Learning
Numerous attempts to define the PBL have been documented in the literature with a great degree of variation and limited consistency. In our efforts, we approached PBL from a principle guided perspective. Three key principles of PBL were described in detail by Hamdan et al.15 These include beginning PBL with problems rather than presenting new information in a lecture format, using problems as the stimulus for student activities within PBL, and approaching PBL from a student centered perspective. These learning activities consist of small groups of students engaging in self-directed analysis of authentic professional practice problems to collectively synthesize solutions.16 Within a PBL context, students identify a problem and work collectively to propose solutions, with the teacher role shifting to that of a facilitator of learning rather than a provider of answers.15,16 The literature provides examples of studies analyzing processes of PBL to validate its use as a teaching strategy that engages students in real-world problem solving and promotes their critical thinking.17,18 Two articles reflect the use of PBL to teach health professions students about quality and safety concepts.19,20 Individual studies have produced significant correlations between PBL and increased critical thinking,15,21 as well as evidence of student satisfaction with PBL20 and techniques.16 Two systematic reviews, 1 from 2011 and a more recent review from 2014 (which included a meta-analysis), analyzed the effectiveness of PBL and recommended PBL as a teaching strategy to improve the critical thinking abilities of nursing students.22,23
Instructional Design
Setting and Participants
We designed a learning activity to teach RCA for students in their fourth year leadership and management course. The setting is a baccalaureate nursing program in a Midwestern state in the United States. The course serves as a capstone for integration of program content and focuses on system issues rather than individual patient issues. This course is offered in 2 forms: in a face-to-face classroom for traditional students and a fully online form for RN-to-BSN students. Approximately 90 to 100 students are enrolled in both forms of the course. The Table provides an overview of the major steps for the project.
Teaching Strategy
The strategy we chose is a mock RCA, using existing medical error cases that have been reported in the scholarly literature and the media. Students were divided into groups of 5 or 6. The activity guidelines included prompts to direct the student groups through the RCA process. The mock RCA followed problem-based learning principles in that the groups participated in a self-directed analysis of an authentic clinical problem and collectively generated proposed solutions.
Implementation Process
The student groups were allowed to use either scholarly literature or media outlets to select an actual medical error case as the basis for their project. After selecting a case, each student group researched published information about the actual error and key information related to standards of care associated with the event and system in which the error occurred. Students then proceeded to identify an RCA team based on the particular case. An important consideration in this process was the identification of the specific contribution that the individual would make to the RCA in relation to the particular system and error involved.
After selecting the case and identifying the RCA team, student groups were required to interview experts. These individuals were experts regarding similar cases to the case selected and/or experts related to the associated standards of care and practice. Examples of experts selected by students include a quality improvement team leader, nurse attorney, nurse manager, pharmacist, surgeon, and staff nurse. The goal of interviewing experts was to help students gain further insight into best practices and standards of care as well as error prevention strategies. Student groups then performed an in-depth literature search to integrate published evidence into their understanding of the case. The project was approved by the authors' university institutional review board.
Evaluation of Student Learning
The methods of evaluation for the project included a formal scholarly paper and a 20-minute in-class or online oral presentation using PowerPoint. The formal written paper included a concise summary of the case, identification of members of the RCA team, identification of documents investigated, consultation with experts, and a risk reduction plan inclusive of specific recommendations for system and process improvements aimed at preventing future errors similar to the case that they selected. The PowerPoint presentation included a summation of the content areas addressed in the paper. The purpose of the presentation component was to allow other students to examine the application of the RCA process to other cases. The paper was worth 50 points and comprised 17% of the student's grade. The presentation was worth 25 points and comprised 8.5% of the course grade. Supplemental Digital Content, http://links.lww.com/NE/A259, provides the assignment guidelines and rubric.
Outcomes and Implications for Practice
This particular educational activity has been successfully implemented in 4 consecutive course offerings. Students have selected a variety of topics and unique cases. Examples of major topics include organ transplantation error, death after central line removal, heparin overdose, and death by overdose from a patient controlled analgesia pump.
The overall student feedback has been positive. The end-of-program evaluations contain 2 items related to quality improvement curricular content. The first item asks: Do you feel prepared to lead quality improvement initiatives on nursing units? In 2013 and 2015, 97% of the students answered "strongly prepared" and "somewhat prepared" to the question. (The item was not included in the 2014 report). The RCA project provided an opportunity to build quality improvement skills as well as confidence to use related tools. The second item asks: Do you feel you are a practitioner who values continuous improvement and demonstrates leadership in quality health care delivery and care outcomes? For that item, 100% of the responses were either "strongly agree" or "agree." The RCA project afforded one means to instill the values necessary to be a nurse who values quality improvement. A rapid cycle improvement process (plan, do, study, act) assignment within the same course may have also contributed to the students' evaluations regarding quality improvement content in the curriculum.
A key consideration for the future is to conduct this as an interprofessional activity and partner with faculty and students from other health care disciplines. Although students currently consult experts from other disciplines, representing those involved in the error in their selected case, this consultation is primarily to elicit information concerning provider experience with similar issues, standards, and best practices. The actual RCA project work is completed by nursing students. Students gained valuable experience participating in the RCA process through the use of actual medical error cases. In addition, this activity equipped students with essential knowledge and skills associated with the overall quality improvement process.
References