Healthcare systems are complex and sometimes unpredictable. Systems fail, and can, on those occasions, make it difficult for RNs to do the very best for their patients. During such times, our first endeavor should be to understand why and how to prevent the same event from occurring in the future.
The first step in developing a solution is to understand how a system failed. The most fundamental reason for the failure or inefficiency of a process, in any work setting, is referred to as a root cause. Root cause analysis is a process of learning from consequences, wherein healthcare providers take a step back and gain knowledge from near misses, adverse events, or sentinel events in the operating room and all areas of healthcare. A root cause analysis should focus primarily on systems and processes, not individual blame.1 It is a shift in culture for both nursing and medical staff.
As a frontline staff member, would you feel comfortable initiating a root cause analysis when you identify quality issues in your department? Most of us would answer no. The concept of this type of approach to problem solving is very familiar to our quality and risk departments, but it doesn't seem to have become part of the bedside nursing culture. For example, when I recently participated in a root cause analysis, one of the attending staff nurses thought she was going to be deposed. This belief and subsequent fear of participation in the root cause process are all too common. The chasm that exists between our quality departments and frontline staff is at times deep and wide. Both sides must claim responsibility to narrow this gap.
As hospitals endeavor to become more transparent with the public regarding patient outcomes, complications, and infection rates, we need to become more transparent between departments. The first step is to educate ourselves and ask our institutions to provide the frontline caregivers with real education-beyond knowing where the policy on sentinel events is contained. The shift from assigning personal blame to one of identifying systems that failed needs to be communicated to all staff. The process of alerting others that there exists a potential for a near miss, or reporting a less-than-optimal outcome, should be embraced. However, there are still institutions that place "incident reports" on staff evaluations. This action creates a culture of "do not tell" instead of having the persons who are best qualified to assist with identifying the system issues that arise and developing innovative solutions.
Providing the documentation of a process that needs improving is not "telling" on other departments; rather, it's seeking the best outcome. The shift to this culture will truly make our hospitals safer. Nurses are the best advocates for their patients and often have novel solutions. However, it means we need to be at the table and involved. If this culture doesn't exist at your institution, remember, it only takes one small voice to start the chorus.
Kate J. Morse
Editor-in-Chief, Assistant Clinical Professor, Acute Care Nurse Practitioner Tract Coordinator Critical Care Nurse Practitioner, Chester County Hospital West Chester, Pa.
[email protected]
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