Using Simulation Technology and The Root Cause Analysis Process to Assess Nurse’s Attitude toward Patient Safety
Journal Title: Biomedical Journal of Scientific & Technical Research (BJSTR) - Year 2017, Vol 1, Issue 2
Abstract
Root cause analysis (RCA) provides an important opportunity for healthcare workers to identify the underlying factors that may contribute to medical errors or sentinel events and subsequently prevent their recurrence. Because of its efficacy, The Joint Commission’s (TJC) recommended RCA framework together with In-situ simulation were used to assess nurses’ attitudes toward patient safety immediately after simulation training and six months later. Thirty-three nurses from a hospital setting participated in RCA sessions which included: a lecture, a simulated patient scenario and debriefing. A 36-item “Safety Attitudes: Frontline Perspectives” survey was given before and after each session and six months’ later. Twelve (39%) nurses responded favorably to patient safety initiatives on the first survey, and twenty-nine (89%) responded favorably after six months (p=0.001). A significant number (p=0.003) of nurses perceived that the institution still needs to improve some patient safety measures. Consequently, In-situ simulation may be an effective tool and have lasting benefits for guiding RCA sessions among nurses. Every year in the US, a number of patients are harmed (estimated 1.5 million) while receiving care in a hospital because of system or human errors [1,2]. For several decades, healthcare experts, professional organizations and medical institutions have been working diligently to identify solutions that will prevent the recurrence of preventable mistakes (National Patient Safety Foundation [NPSF], 2015; Patient Safety Network [PSNET], 2014). Some of these mishaps have resulted in an unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury (sentinel event) to a patient or patients, not related to the natural course of the patient’s illness (The Joint Commission, 2010). Thus, the TJC recommends that all healthcare organizations conduct a root cause analysis (RCA) to determine the underlying cause of the event and develop a prevention strategy to eliminate any recurrences of the same or similar mistakes (The Joint Commission, 2010). Although RCAs were originally developed by industrial companies to analyze accidents, healthcare organizations routinely use this method as a tool to analyze medical errors [3]. In most instances, a RCA protocol is used to collect data and reconstruct the event through participant interviews and medical record review (NPSF, 2015). These results should identify the sequence of events leading to the error and some possible underlying causes. James Reason’s “Swiss Cheese Model” is commonly used to describe a systemic approach to RCAs. This approach helps to identify both active errors (occurring at the point of interface between humans and complex systems), and latent errors (the hidden problems within health care systems that contribute to adverse events) [4]. One key element of an RCA is to avoid focusing on human mistakes and increase efforts to identify underlying problems that might increase the likelihood of errors [5]. Although the efficacy of RCAs has not been thoroughly studied in healthcare, it is a widely-used approach to improving patient safety [5]. Though healthcare organizations and providers embrace this approach, few formal mechanisms exist for analysis of multiple RCAs across institutions [5]. According to some researchers there is no consensus on how hospitals should follow up or analyze RCA data. This inhibits the utility of RCA as a quality improvement tool [6]. However, a repository of RCAs may help organizations identify patterns of errors and lead to solutions designed to prevent common mistakes [7]. Korndorffer & Slakey’s et al., [8] research suggests that routine, memory-based reviews of sentinel events in healthcare may not yield enough information to allow an improved evaluation of the entire system. They imply that using a similar approach to assist in evaluating adverse events as high-reliability industries outside of medicine may be more feasible, since these organizations evaluate the adverse event using a context and environment that are similar to those of the original event [8]. Researchers suggest that simulated environments in healthcare can be used to recreate the event and allow more people to participate in the encounter and not just those involved in the actual event [9,10]. The discussion of a sentinel event with staff nurses has been a difficult task for both managers and employees because human factors do not allow total transparency [11]. Nurses are responsible for most medication and other errors committed in health care organizations because they are accountable for administering medication and a variety of technical procedures [12]. Nurses are also considered as the final safeguard before the patient receives the medication or undergoes a procedure [13]. Therefore, nurses have been the target of the shame and blame associated with medical errors that result in sentinel events. Nurse’s state that the process to review a sentinel event in an effort to perform a RCA has been demoralizing, embarrassing and most of all traumatizing [11]. Hence, this study approached the RCA process differently, using a collaborative effort to combine In-situ simulation teaching strategies as a way of helping nurses understand various patient safety initiatives [9].
Authors and Affiliations
Ruth Everett-Thomas, Lee Fong-Hong, Elizabeth Joseph, Marlene Augustine, Ilya Shekhter, Lisa F Rosen, David J Birnbach
Keywords
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- EP ID EP567144
- DOI 10.26717/BJSTR.2017.01.000192
- Views 176
- Downloads 0
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