'SWARMing' to Improve Patient Care: A Novel Approach to Root Cause Analysis

摘要

Background: When errors occur with adverse events or near misses, root cause analysis (RCA) is the standard approach to investigate the "how" and "why" of system vulnerabilities. However, even for facilities experienced in conducting RCAs, the process can be fraught with inconsistencies; provoke discomfort for participants; and fail to lead to meaningful, focused discussions of system issues that may have contributed to events. In 2009 University of Kentucky HealthCare Lexington developed a novel rapid approach to RCAs-colloquially called "SWARMing"-to establish a consistent approach to investigate adverse or other undesirable events. Methods: In SWARMs, which are conducted without unnecessary delay after an event, an interdisciplinary team undertakes thoughtful analysis of events reported by frontline staff. The SWARM process consist of five key steps: (1) introductory explanation of the process; (2) introduction of everyone in the room; (3) review of the facts that prompted the SWARM; (4) discussion of what happened, with investigation of the underlying systems factors; and (5) conclusion, with proposed focus areas for action and assignment of task leaders with specific deliverables and completion dates. Results: Since its implementation, incident reporting increased by 52%-from an average of 608 incidents per month 0une-December 2011) to an average of 923 per month (January-May 2014). The overall health system experienced a 37% decrease in the observed-to-expected mortality ratio-from 1.17 (October 2010) to 0.74 (April 2015). Conclusion: SWARMs, more than an error-analysis exercise or simple RCA, represent an organizational-messaging, culture-changing, and capacity-building effort to address the challenges of creating and implementing processes that serve to promote transparency and a culture of safety.