How Much of Root Cause Analysis Translates into Improved Patient Safety: A Systematic Review
Por:
Martin-Delgado J, Martínez-García A, Aranaz JM, Valencia-Martín JL and Mira JJ
Publicada:
1 dic 2020
Ahead of Print:
15 may 2020
Categoría:
Medicine (miscellaneous)
Resumen:
Objectives: The aim of this systematic review was to consolidate studies to determine whether root cause analysis (RCA) is an adequate method to decrease recurrence of avoidable adverse events (AAEs). Methods: A systematic search of databases from creation until December 2018 was performed using PubMed, Scopus and EMBASE. We included articles published in scientific journals describing the practical usefulness in and impact of RCA on the reduction of AAEs and whether professionals consider it feasible. The Mixed Methods Appraisal Tool was used to assess the quality of studies. Results: Twenty-one articles met the inclusion criteria. Samples included in these studies ranged from 20 to 1,707 analyses of RCAs, AAEs, recommendations, audits or interviews with professionals. The most common setting was hospitals (86%; n = 18), and the type of incident most analysed was AAEs, in 71% (n = 15) of the cases; 47% (n = 10) of the studies stated that the main weakness of RCA is its recommendations. The most common causes involved in the occurrence of AEs were communication problems among professionals, human error and faults in the organisation of the health care process. Despite the widespread implementation of RCA in the past decades, only 2 studies could to some extent establish an improvement in patient safety due to RCAs. Conclusions: RCA is a useful tool for the identification of the remote and immediate causes of safety incidents, but not for implementing effective measures to prevent their recurrence.
Filiaciones:
:
Atenea Investigation Group, Fundación para el Fomento de la Investigación Sanitario y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain,
Martínez-García A:
Department of Health Psychology, Universidad Miguel Hernández, Alicante, Spain
Aranaz JM:
Preventive Medicine Service, Hospital Ramon y Cajal, Madrid, Spain
Valencia-Martín JL:
Preventive Medicine Service, Hospital Ramon y Cajal, Madrid, Spain
:
Atenea Investigation Group, Fundación para el Fomento de la Investigación Sanitario y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
Department of Health Psychology, Universidad Miguel Hernández, Alicante, Spain
Alicante-Sant Joan d'Alacant Health District, Alicante, Spain
Green Published, gold
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