The Root of the Matter

When adverse events occur, institutions turn to root cause analysis to pinpoint weak areas and improve patient care


Two patients with the same last name were on the same floor of a major hospital in Houston, Texas, both scheduled for procedures on the same day. Attendants wheeled the patients to their respective procedure areas in the hospital.

That’s when hospital personnel realized something was amiss. The patients had been taken to the wrong areas — each about to receive the other’s procedure. Fortunately, the error was discovered before the procedures began, but the incident still raised significant concerns. How did such a mistake occur when the hospital had extensive safeguards in place to prevent such a mishap? And how could future incidents be prevented?

Milton J. Guiberteau, MD, FACR, professor of radiology at Baylor College of Medicine, in the Texas Medical Center, says that while the most convenient answer was that the transporters were to blame, that wasn’t necessarily the fundamental cause of the incident. To better understand how the mistake occurred, the hospital performed a root cause analysis (RCA) — a retrospective investigation to identify failures within an organization’s processes. “It’s human nature toimmediately jump to an initial conclusion that is usually the most obvious cause,” Guiberteau says. “But many things must be evaluated before you can decide what the primary system error was.”

The hospital’s quality care team gathered representatives from every department involved in the care of the patients in question — including radiology — and two uninvolved staff members to provide objectivity as the group discussed and documented how the incident unfolded. They studied everything from the procedure orders to how the patients were identified for transport. At the conclusion, the team determined that the root cause was a breakdown in the process used for patient identification. “Patients must be identified not by the way they look, not by the room they’re in, not even by their names, but instead by their medical record identification numbers,” says Guiberteau, who participated in the RCA. “Those numbers need to be checked without exception during every interaction with a patient. We’ve been hammering that lesson in ever since.”

To Analyze or Not

RCA is used across industries to identify and resolve system failures. In health care, the Joint Commission requires that institutions conduct root cause analyses for all sentinel events — unexpected deaths or serious injuries to patients and incidents that put patients at significant risk of adverse outcomes. In radiology, sentinel events may include falls during a procedure, dose-related errors, procedural complications, and contrast extravasations. But radiologists can provide value to an RCA even when an event occurs outside of radiology, says Sumir S. Patel, MD, chief resident at Georgia Regents Medical Center. “We have an overarching perspective on the care that patients receive, and that helps in the RCA because we can piece together a timeline and details that may not be as evident to other clinicians,” Patel says.

While an RCA is required for any sentinel event, an institution may also conduct the analysis for less serious incidents. For instance, the radiology department at Georgia Regents Medical Center conducted an RCA to identify ways to streamline its workflow for fluoroscopy-guided lumbar punctures. “We had an inefficient process that took a lot of time before, during, and after the procedure,” Patel says. “We wanted to determine what the bottlenecks were in that process and how to fix them.” Radiologists assumed that transport issues were bogging down the process, but through RCA they discovered several other contributing factors. “We addressed all of those issues to a certain degree, reducing the time it takes for lumbar punctures significantly more than if we had just addressed the transport problem,” Patel says.

Institutions determine whether nonsentinel events warrant an RCA and who should be involved in the analysis. “The threshold for performing a root cause analysis is set both at the regulatory level by the Joint Commission as well as at the institutional level, which might require all adverse events and even some near misses to undergo such a process,” saysJonathan B. Kruskal, MD, PhD, professor of radiology at Harvard Medical School and chair of the department of radiology at Beth Israel Deaconess Medical Center. Kruskal says that every trainee in his department must participate in an RCA during residency. The exercise helps trainees identify factors that can lead to adverse events so that they can address those issues before such an event occurs.

The RCA Way

Once an institution or department decides to perform an RCA, it follows prescribed guidelines for conducting the analysis: identify the adverse event, gather data through interviews with everyone involved in the event, analyze and prioritize possible causes, identify the root causes, generate solutions, and devise methods for disseminating the results and implementing corrective measures.1 James V. Rawson, MD, FACR, chair of radiology and imaging and chief of radiologic services at Georgia Regents Medical Center, notes that the goal of an RCA is to identify system lapses rather than to place blame on individuals. “A peer review or a morbidity and mortality conference might focus more on the role an individual played in an outcome, but a root cause analysis looks for system flaws,” he says.

For a successful RCA, an institution must establish an atmosphere that allows people to talk about the event without fear of ridicule. “Everyone must be assured that their thoughts are being taken seriously and that they can speak without being judged or blamed,” Guiberteau says. Rawson uses an analogy from the automobile industry to explain the purpose of an RCA. In the past, when automobiles could be started while in reverse, many people accidentally struck their children in their driveways. While the obvious conclusion was that the drivers were to blame for the accidents, the root cause was that automobiles could be started in reverse, Rawson explains. Once carmakers eliminated that ability, those accidents decreased dramatically. “Using such an analogy at the beginning of an RCA illustrates that we are looking for flaws in the workflow and process that allowed us to make the mistake,” Rawson says.

The success of an RCA is also dependent on the information gathered during the interviews. “The value of an RCA is being able to look at the incident as a combined-care team to identify potential system flaws and how to improve them,” Rawson says. “So one of the biggest pitfalls of an RCA is not getting all of the stakeholders in the room at the same time.” Guiberteau says he has learned a lot about operations in other hospital departments by participating in root cause analyses. “I’ve been around a long time, but I had never before got down to that level of understanding of what my nonradiology colleagues do in their corners of the hospital and the complexities that they deal with,” he explains. “The experience is rewarding.”

The Benefit of Change

Perhaps the most important step in an RCA is the follow-through. Once the root causes have been identified and solutions developed, corrective measures must be implemented. In the case at Texas Medical Center, each department offered recommendations to the quality care team for improving patient identification. Then, transfer documents were introduced to remind staff that continuity of identification is critical, and follow-up meetings were held at three and six months to gauge the effectiveness of solutions. In more complex cases with multiple root causes, it may take longer to realize results.

While conducting an RCA takes time and effort, the benefits for institutions and patients are significant. Through the analysis, institutions can eliminate inefficiencies in processes they use every day, which gives physicians more time for patient care. RCA also helps resolve issues that lead to adverse patient outcomes, reducing the likelihood of future incidents. “Performing root cause analyses and implementing change raises the overall quality and, therefore, the value of our services to all of our customers,” Kruskal says.

Furthermore, RCA is a powerful tool for meeting the objectives of ACR’s Imaging 3.0™ initiative. It advances the role of radiologists by bringing radiologists and personnel from other departments together to solve challenges and improve patient care. “Being an active player in the root cause analysis can get your face out there,” Patel says. “It gets you out of the dark reading room and really helps show your referring physicians that you are there, you are part of the patients’ care, and you’re there to help provide the highest quality of care possible.” 

And Read This Too 

Visit the JACR for more information on root cause analysis in radiology. A good place to start is "Illustrating the Root-Cause-Analysis Process."Cause-Analysis Process." 

By Jenny Jones, freelance writer for the ACR Bulletin

1. Vaishali R, et al. Illustrating the root-causeanalysis process: creation of a safety net with a semiautomated process for the notification of critical findings in diagnostic imaging. JACR 2005;2:76876.


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