A Bottom-Up Approach to Understanding the Efficacy of Event-Analysis in Healthcare: Paradigm Shift from Safety to Resilience Engineering

摘要

Root Cause analysis (RCA) is a widely implemented event-analysis tool in healthcare, used to improve patientsafety. Several studies have assessed the effectiveness of RCA solutions and provided recommendationsfor improving the approach; however few have suggested a systematic approach to align RCA-basedinterventions with the realities of work practice in healthcare. In this study, semi-structured interviews wereconducted with frontline healthcare staff (nurses, nurse managers and technicians) in order to assess theirperspectives on the effectiveness and sustainability of RCA-based solutions in a large academic medicalcenter. In general, preventive interventions such as physical environment or equipment changes were moreeffective and sustainable than reactive or passive measures such as reviews and compliance checks. A thematicanalysis of respondents’ narratives highlighted several issues related to the design and implementationof various RCA-driven interventions. The analysis however, also revealed important facets of frontlinemedical practice, including the role played by staff in overcoming systemic hazards in order to increase patientsafety. These findings are discussed in the context of the emerging Resilience Engineering approach tosafety in complex systems.