RCA is a review by interprofessional team, it’s very important for the RCA to be done by an interprofessional team, experts from different department from different specialties and subspecialties knowledgeable about the process involved in the event. It’s also the analysis of the systems and the processes, rather than individual performance.
RCA = deep analysis.
It’s not just a matter of what happened. But also why did it happen in the first place? plus all aspects of the process are reviewed and contributing factors and considered, this is very important because, essentially what we need is it’s not a matter of blaming someone for the error and that’s it, let him get sued or whatever or fired. It’s a matter of how we want to develop the system as a healthcare facility so that this error does not happen again, so this particular kind of error does not happen again. So that’s why we need deep analysis.
It’s also the identification of potential improvements to improve the performance and to reduce the likelihood of such adverse events in the future. This is very important. These are the characteristics of the root cause analysis.
<h3><strong>Discourage using memory</strong></h3><p><a href="https://www.obaid.info/a-patients-bill-of-rights/" target="_blank" rel="noopener">Clinicians </a>are busy, there are more and more things that we you have to remember, don’t rely on your <a href="https://www.verywellmind.com/what-is-memory-2795006" target="_blank" rel="nofollow noopener">memory</a>. Don’t say "I'll remind this, I will write it later on, I will call make the phone call later, I'll put in the medical record later". So don't rely on the memory. You can use checklists, you can use flow sheets, you can use ticker systems, the medical records themselves can be divided clearly into sections, and each section is clearly labeled. And now, even they have <a href="https://www.tomsguide.com/best-picks/best-tablet" target="_blank" rel="nofollow noopener">tablet devices</a>, it's okay to use them, it's better than relying on the memory and end up missing something or forgetting something.</p> <h3><strong>Provide information access</strong></h3><p>Also, there should be improved information access, okay, like the handheld computers, the <a href="https://www.obaid.info/himss-certification/" target="_blank" rel="nofollow noopener">electronic medical records</a>, in a way, it's it helps a lot in preventing medical errors, for example, the error proofing systems, if the systems are programmed, not to accept, for example, a drug for adults should not be given for children. And if the patient is a child, then the system can send an alert to you that this action will be given to this patient because this patient is a child for example. Or if there's a drug interaction, you can’t prescribe this drug and also the kind of error proofing system.</p> <h3><strong>Facility wide standards</strong></h3><p>This is also the issue of standardization, it's very important when it comes to standardization, that within the facility, you should be following the same guidance, the same policies, the same clinical guidelines, it's very important to make sure that our practice is standardized. And this is perhaps the issue of quality and quality assurance within each health facility and these requirements for accreditation obviously. So, there should be office firmer these guidelines and since this is within the health facilities, they are reachable, they are accessible, you can reach them, you can approach them to make sure that you what you are doing is following the standards.</p> <h3>Train hospital staff how to find and eliminate medical errors</h3><p>Also training on early identification and prevention. It's also important to keep on training staff on <a href="https://www.obaid.info/prevention-and-management-of-medication-errors/" target="_blank" rel="nofollow noopener">medical errors</a>, tuning the staff on the policies, training staff on infection control and so on and so forth to avoid or to minimize as much as possible the potential of medical errors, the prevention of surgical errors also there are elements where the <a href="https://www.who.int/" target="_blank" style="outline: none;" rel="noopener">WHO </a>is suggesting, certain elements, what they call the this surgical checklist which is an algorithm listing the actions the listing of actions to be taken in given clinical situation intended to make everyone aware of others expected actions.
The checklist must be completed before the induction of anesthesia. So basically sign in before the induction of anesthesia. We have to answer these questions. It should be straightforward and kind of an easy so it might seem a simple thing but it’s for the sake of everyone.
Has the patient confirm identity, site procedures and consent it should be ready, surgical site should be marked in the history and physical examination present is anesthesia machine and medication check complete are diagnostic radiological test present, are blood products available in case blood transfusion is needed, is special equipment devices and implants present.
Does the patient have non allergy the should be written clearly on the medical record, difficult airways or aspiration risk and risk of more than 500 milliliter blood loss or seven milliliter per kg., this should be answered very, very clearly.
We have been introduced to the Accident Causation Model or as known as “Swiss Cheese Model”.
We’re going to talk about the prevention and management of medical errors.
Medication errors 101.