Learning by 'SWARMing' Adverse Events

摘要

Essential to improving the safety of patient care is learning from instances when processes and/or outcomes are well below standards of care or expectations. One important improvement tool has been root cause analysis (RCA), which is used to identify weaknesses in both micro- and macroys-tems of care and to design countermeasures to prevent or at least reduce suboptimal care. The use of RCA and "5 Whys" principles contributed importantly to the reliability journey led by Sakichi Toyoda at Toyota and subsequently by others in military and commercial aviation. The 2000 report To Err Is Human reflected and led to further awareness by the Institute of Medicine2 and others that the safety of patient care needed to be a focus of concern in the United States-and worldwide. The Joint Commission has identified sentinel events-a group of situations or patient outcomes that were serious and almost always preventable-and mandated accredited organizations' use of formal RCA when they occurred to improve subsequent care. Increasingly transparent attention to sentinel events-and, particularly, their derivative human suffering-was sobering to clinical and nonclinical leaders and motivated hospitals to establish or enlarge patient safety programs. To enhance the benefit of improvement work that follows serious safety events, the National Patient Safety Foundation (NPSF) convened an expert panel, which recently developed important improvements to and specific supporting tools for the more action-focused Root Cause Analysis and Action (RCA~2).