If you are a hospitalist or a resident or work in a hospital, please read this blog post from Bob Wachter – How UCSF’s Root Cause Analysis Process Became Our Most Useful Patient Safety Activity
But I’m quite confident that our RCA transformation has been the most powerful thing we’ve done to improve safety. While some safety fixes (such as computerization and incident reporting systems) have been less useful than I would have expected, our RCA process has been more effective – because it really is much more than an error-analysis exercise. It is an organizational-messaging, culture-changing, capacity-building process.
At our university hospital, we have a similar hospital. Bob is spot on, this should become a defining activity of excellent hospitalist programs and of excellent hospitals.
At our recent Academic Hospitalist Academy, we did devote one session to safety and root cause analysis. The participants all made thoughtful contributions to the sessions.
We have written recently about the importance of safety.
We suggest studying hospitalist groups and their structure. Hospitalists can bring their greatest value when they become integrated into the hospital culture. Given the confusing term quality, we recommend focusing on safety issues rather than core disease measures as indicators of hospitalist contributions. Hospitalists have the best opportunity to observe process variations that increase the risk of a serious adverse outcome—or sentinel event. The salient question thus should focus on what do hospitalists do with these observations, or at a higher level, what can they do about dangerous processes. Thus, we should understand the preparedness and ability of hospitalists to assume roles and contribute to safety efforts as well as hospital support and commitment to addressing these important efforts. All physicians who have experienced these lapses in care understand that preventing error recurrence has more meaning and likely more impact than documenting smoking cessation counseling on discharge.
Please read Wachter's post. Please
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I posted a rant about this at Dr Wachter's website. At my 1st re-reading of it after it posted, I ws concerned that I had been intemperate in my criticism. Reading it yet again, I'm not concerned about that. I'm concerned that you have fallen for the old time religion of Let's Have a Meeting.
You are admirably in favor of evidenced based medicine. I read through Wachter's post looking for any evidence that all of this frenzied activity actually does any verifiable good. They meet, they discuss, they come to a shared understanding. They function more effectively as a committee. Absent is any hard data that indicate that bad stuff happens less now than it did back then. There is no question that they are spending a lot of time that otherwise would be available to fulfil the core mission of the institution (patient care). They also believe that it makes the front-line caregivers more appreciative of the efforts of their administrators. Clearly they have never spent any time on a patient care ward nursing station- all they ever talk about is how wam-and-fuzzy they feel about their administrators.
This would be worth it if there were evidence, numbers that indicate that bad things happen less often. But there is no evidence. Just the warm self-congratulatory feelings that come from an administrator convening yet another meeting. It just has to work, right?