TY - GEN
T1 - A bottom-up approach to understanding the efficacy of event-analysis in healthcare
T2 - 57th Human Factors and Ergonomics Society Annual Meeting - 2013, HFES 2013
AU - Hegde, Sudeep
AU - Hettinger, A. Zach
AU - Fairbanks, Rollin J.
AU - Wreathall, John
AU - Lewis, Vicky
AU - Wears, Robert
AU - Bisantz, Ann M.
PY - 2013
Y1 - 2013
N2 - Root Cause analysis (RCA) is a widely implemented event-analysis tool in healthcare, used to improve pa-tient safety. Several studies have assessed the effectiveness of RCA solutions and provided recommenda-tions for improving the approach; however few have suggested a systematic approach to align RCA-based interventions with the realities of work practice in healthcare. In this study, semi-structured interviews were conducted with frontline healthcare staff (nurses, nurse managers and technicians) in order to assess their perspectives on the effectiveness and sustainability of RCA-based solutions in a large academic medical center. In general, preventive interventions such as physical environment or equipment changes were more effective and sustainable than reactive or passive measures such as reviews and compliance checks. A the-matic analysis of respondents' narratives highlighted several issues related to the design and implementa-tion of various RCA-driven interventions. The analysis however, also revealed important facets of frontline medical practice, including the role played by staff in overcoming systemic hazards in order to increase pa-tient safety. These findings are discussed in the context of the emerging Resilience Engineering approach to safety in complex systems.
AB - Root Cause analysis (RCA) is a widely implemented event-analysis tool in healthcare, used to improve pa-tient safety. Several studies have assessed the effectiveness of RCA solutions and provided recommenda-tions for improving the approach; however few have suggested a systematic approach to align RCA-based interventions with the realities of work practice in healthcare. In this study, semi-structured interviews were conducted with frontline healthcare staff (nurses, nurse managers and technicians) in order to assess their perspectives on the effectiveness and sustainability of RCA-based solutions in a large academic medical center. In general, preventive interventions such as physical environment or equipment changes were more effective and sustainable than reactive or passive measures such as reviews and compliance checks. A the-matic analysis of respondents' narratives highlighted several issues related to the design and implementa-tion of various RCA-driven interventions. The analysis however, also revealed important facets of frontline medical practice, including the role played by staff in overcoming systemic hazards in order to increase pa-tient safety. These findings are discussed in the context of the emerging Resilience Engineering approach to safety in complex systems.
UR - https://www.scopus.com/pages/publications/84889779245
U2 - 10.1177/1541931213571146
DO - 10.1177/1541931213571146
M3 - Conference contribution
AN - SCOPUS:84889779245
SN - 9780945289432
T3 - Proceedings of the Human Factors and Ergonomics Society
SP - 673
EP - 677
BT - Proceedings of the Human Factors and Ergonomics Society Annual Meeting, HFES 2013
Y2 - 30 September 2013 through 4 October 2013
ER -