Introduction
Investigation of adverse events is an essential component to patient safety and quality improvement in healthcare. Derived from manufacturing engineering, root cause analysis (RCA) is one of a number of investigation methods now widely used in healthcare [
1,
2]. RCA seeks to obtain an in-depth understanding of system safety issues and to facilitate improvements by implementing recommendations [
3].
While there are more than 40 RCA techniques used in healthcare, all versions use a structured process for creating chronological maps, undertaking interviews and analysing other data, and developing cause-effect diagrams and recommendations [
4,
5]. A small multidisciplinary team is appointed and utilises analytical and problem solving techniques to determine causation and subsequent recommendations for improvement, which, if implemented should minimise the risk of recurrence [
6].
Criticism of RCA has focused on its equivocal results in improving patient safety [
7‐
9], its flawed focus on a “single root cause based on a simple linear narrative that displaces more complex, and potentially fruitful accounts of multiple interacting contributions to how events really unfold” (p. 417) [
9] and challenges in translating RCA methods into practice [
10‐
12]. Weak recommendations, a focus on active failures over latent organisational issues, lack of generalisability, and poor quality of RCAs are also routinely reported [
4,
9,
11,
13]. Consequently, some organisations are moving towards more flexible patient safety investigation methods [
14,
15] and/or refined RCA approaches [
16]. Nevertheless, despite criticisms, RCAs are embedded into policy and practice in many health systems across the world and will continue to play an important role in making healthcare safer if it becomes better at delivering benefits [
9]. An understanding of the issues encountered during RCAs can be used to inform changes in how they are conducted.
The RCA process is complex and challenging and there are numerous barriers to its use in practice [
9,
12,
17,
18]. A procedure-oriented approach in RCAs can lead to the mishandling of emotions and blame, and have flow-on impacts on the quality of findings [
18]. Interpersonal issues are especially relevant for RCA team members charged with interviewing their colleagues, with concerns about “
how to break the news to colleagues that this RCA is under way; how to make sure questions are asked in ways that do not upset people…and how to rescue relationships with the interviewees in case the latter become defensive or anxious” (p. 1608) [
19]. However, the experiences of RCA team members (i.e. those not directly involved in incident, but providing clinical expertise) has been little studied.
The aim of this study is to better understand the experiences of RCA team members and how they value their involvement in the RCA. These findings will be used to potentially inform future recruitment, conduct and implementation of RCA findings into clinical practice.
Discussion
This study is important because it addresses a research gap in RCA team members’ experiences of RCAs. RCA team members reported mixed experiences of RCAs, ranging from enjoyment and the perception of worth and value to concerns about workload and lack of impact. Nevertheless, the RCA team members learnt from the process and it led them to reflect about their own practice. Similarly, it has been shown that involvement in RCAs may improve patient safety culture [
28,
29]. This may be facilitated by improved teamwork and communication, and trust and openness, from bringing staff together from different disciplines [
12,
29,
30]. Our study also suggests that staff willingness to undertake the responsibility of extra duties related to RCAs is important to the conduct of RCAs. This study did not identify conflicts between RCA team members and clinicians or unwillingness to participate in the investigation process [
29].
These study findings are notable in light of the widely reported limitations to RCAs and implementation of its recommendations [
8]. For example, recommendations are difficult to implement [
31], result in little change [
7,
9,
10], and are not widely shared, sustainable or connected with practice [
18]. Additionally, despite a perceived need to be aggregated in order to generate system level improvements, this does not routinely occur [
32], resulting “in failure to disseminate painfully acquired learning and to address deeper, institutionally engrained patient safety concerns” (p. 418) [
9]. The type and strength of RCA recommendations may be classified using US Department of Veterans Affairs criteria [
4,
33,
34], generally, system-based interventions such as forcing functions and automation or computerisation are more effective than person-based approaches [
35].
Our participants reflected these known concerns about RCA recommendations, in particular the possible benefits from aggregation of RCA recommendations across local health networks. However, a barrier to sharing of learnings and recommendations across networks is that the legislative privilege reduces the amount of detail that can be provided in recommendations, such that “
it’s very hard to actually produce something which can be usefully applied to change practice without providing details” (P1, FG3). The intention of legislative privilege is to encourage health service staff’s voluntary participation in RCAs and assure interviewees directly involved in the incident that the investigation is confidential and protected from discovery, for example, by the media. The legislative privilege is a balance between providing confidentiality to promote willing and robust participation, and some transparency about processes and outcomes that can permit others to learn from lessons identified by the RCA team [
24]. Herein lies the trade-off at the heart of the legislative privilege – while it enhances disclosure it limits the utility of the consequent recommendations – such that it seems unlikely that sharing of reports and recommendations across networks can occur under legislative privilege. Nevertheless, some local health networks, are currently piloting the conduct of some RCAs without privilege; this may provide an opportunity to test the sharing of RCA recommendations and whether the inherent desire to protect reputation that impedes identification of organisational failures can be overcome [
36]. In other jurisdictions, the final RCA report may be shared to assist implementation, while the interviews cannot be shared [
14].
Participants referred to recommendations using terms such as ‘gold standard’ and ‘very strong’, which contradicts a number of retrospective studies that describe predominantly weak recommendations from RCAs [
4,
17]. This disparate finding may reflect the different perspectives of those embedded in the development of recommendations. The participants trusted the process of the RCA and that implementation of the recommendations would take place outside of their spheres of influence. However, if RCA participants with intimate knowledge of recommendations were more involved in their implementation [
31] then this would help to inform the implementation and keep participants informed about the implementation, thereby addressing barriers raised in this study. The literature suggests that there are few incentives to formally follow-up on the implementation of recommendations. While 45–70% of recommendations may be implemented, they may not be implemented thoroughly or may be abandoned shortly thereafter [
9,
37].
Participants’ expressions of concern and desire to support their colleagues being interviewed during the RCA was a very strong theme of the focus groups. Although intended as a rational activity, the interaction of the socio-technical aspects of the RCA are emotionally fraught with anxiety, fear and shame, and concerns about judging clinical practice and being agents of ‘the bureaucracy’ [
10,
18]. Guthrie emphasises the requirement to ensure psychological safety for participants and acknowledges the interview process can be intimidating and ‘scary’ for staff [
38]. Accordingly, interviewers should be empathic and aware of vulnerability of the staff whose actions have potentially contributed to an adverse outcome [
38]. The participants also recommended that supports should be implemented acknowledging staffs’ participation. This support could be in the form of a letter, a neutral support person or some other correspondence from a senior staff member.
Limitations
We were only able to recruit 2–3 participants each to a total of 3 focus groups. The small number of participants per focus group may have limited the interaction between participants, and thereby the effectiveness of the method. Nevertheless, the results obtained were sufficient to provide a clear understanding of experiences across a range of clinical backgrounds. Although the findings were generally consistent, the inclusion of more focus groups and/or participants may have led to new findings. We do not claim that data saturation was reached, but note that the importance of saturation in determining sample size of qualitative studies is increasingly contested [
39,
40]. As a group activity, focus group participants may be less inclined to divulge confidential, or less socially acceptable viewpoints. Additionally, some participants worked with and knew the Clinician Governance Unit-based co-interviewers, which may have impacted their responses. Finally, those who declined to participate may have had negative experiences with RCAs, which could lead to the under-representation of negative perspectives.
Conclusion
RCA team members suggested that participating in RCAs was a worthwhile process that appropriately explored key system issues involved in adverse events. RCAs were perceived as promoting a safety culture for the organisation, however, barriers to participating in RCAs resonated with other studies. The use of legislative privilege hindered the sharing of meaningful learnings for dissemination across the wider health service. Implementing RCA recommendations in isolation, without a comprehensive understanding of the details of the incident, potentially impacts on uptake.
This study should reassure clinicians of the perceived value of RCAs in reviewing significant adverse patient incidents. Improvements can be made in the way that learnings from RCAs can be shared to make effective improvements in health care. This study builds on current literature by suggesting a process to support interviewees and strengthen the process for post-RCA interview follow up and acknowledgement of RCA participation.
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