Patient Safety Tip of the Week


March 30, 2010

Publicly Released RCA’s: Everyone Learns from Them


In addition to The Joint Commission’s sentinel event database, virtually all states have incident reporting systems that collect information about serious events that take place in our health systems. Some include near misses in addition to those incidents in which actual patient harm occurred. The debate continues to rage as to whether mandatory or voluntary reporting systems should be used and there are good arguments for and against each. Mandatory systems capture only a small fraction of serious events that take place and most do not include near misses, which are potential sources of great lessons learned. Voluntary systems capture far more reports as long as they remain confidential. There are certainly examples where incident reporting systems intended to be confidential (not just in healthcare) have been subject to freedom of information requests, legal challenges, or security leaks. When that occurs there usually follows a significant reduction in reporting incidents. The result is that many valuable patient safety lessons never get disseminated.


But here is the more important problem: these incident databases are rich sources of lessons learned that can be used by virtually every healthcare organization. Yet those lessons seldom get disseminated. Typically what happens is that the keepers of the databases wait until they have several similar significant incidents and then they publish a summary of the incidents with key learnings and recommendations. That is what occurs from The Joint Commission, The Pennsylvania Patient Safety Authority, The New York Patient Occurrence and Tracking System, the National Patient Safety Agency (UK), and countless others.


Contrast that to what the Institute for Safe Medication Practices (ISMP) does. They often publish a valuable lesson even when they have received notice of only a single instance of such occurrence. Yet what they publish are lessons that can be used by every hospital or healthcare organization. When you read their safety alert newsletters, you always find yourself saying “I wonder if that could occur here.”.


It is very rare that we get the opportunity to learn from good root cause analyses (RCA’s) on individual cases. We have discussed a few in past columns (see our Patient Safety Tips of the Week for November 17, 2009 “Switched Babies”, January 29, 2008 “Thoughts on the Recent Neonatal Nursery Fire”, September 11, 2007 “Root Cause Analysis of Chemotherapy Overdose”). But this month we have a unique opportunity to take back lessons from several individual RCA’s done on incidents that occurred in a pediatric hospital in Alberta, Canada. The Healthcare Quality Council of Alberta has issued a public report on the RCA’s done on four incidents there. This document is a great teaching tool, both for teaching how to conduct RCA’s and for the lessons learned.


The first case discussed was one in which enteral feedings were inadvertently given intravenously. The hospital lacked enteral infusion pumps so it used parenteral infusion systems and SMART pumps to infuse enteral feedings into the GI tract. Because these were complete parenteral systems, they lacked the constraints we use to prevent enteral syringes from being attached to IV lines, etc. (see our July 10, 2007 Patient Safety Tip of the Week “Catheter Connection Errors/Wrong Route Errors”). In addition to the inappropriateness of the equipment/supplies here, there was also a failure to appropriately label all tubes/lines and to trace all tubing back to its source before putting anything into the tubing, lack of familiarity with the care plan, and suboptimal handoffs.


Contributing factors were acquiescing to the family’s wishes not to wake the patient to trace the tubing back to its source, pressure to tend to multiple patients at the same time, and last minute changes in patient assignments.


But just as important in this case was a critical lesson on lessons learned. In 2006 there had been a similar incident at the same hospital in which expressed breast milk was inadvertently given intravenously. After that incident an extensive root cause analysis was done and multiple recommendations were made, including key recommendations that should have prevented the current incident. But all those recommendations had not yet been fully implemented. More importantly, the recommendations were communicated back to those individuals deemed to be in the “need to know” but not widely disseminated to middle for front line management nor to front line staff. The current RCA  talks about the need to “tell stories” as a patient safety tool. Our regular readers know that we agree storytelling is a far more powerful tool than policy or procedure changes and is almost as strong an intervention as the forcing functions and constraints that could have prevented the current episode (see our December 2009 What’s New in the Patient Safety World column “Stories, Not Statistics”). A nurse or a doctor who has heard the story of that previous disaster is much more likely to trace the tubing back to its source before administering anything into that tube than a new nurse or doctor who is “just following policy”.


The current RCA also noted that the previous recommendations were neither prioritized nor audited for compliance. A good RCA always includes a section for how you will measure whether your intervention is effective or not. Auditing for compliance with the recommendation is a good way to identify whether your risky situations continue. Think about this issue at your organization: how many times have you done an RCA and found that your frontline staff were completely unaware of an intervention you thought you had implemented after a previous incident? We will answer that for you: it happens all the time!


An RCA on a second incident (an overdose of Fentanyl) illustrated the cascade of errors that we typically see before harm actually comes to a patient. The case began with a breakdown in communication between a physician and nurse during a verbal order. Presumably there was an issue with the physician because much of the RCA was spent discussing the problems caused by disruptive physicians and the need for a zero tolerance approach to such. Then there was a failure to perform a truly independent double check on the ordered medication prior to administration. The discussion centers on the fact that many health care providers confuse a routine double check with an independent double check. In the latter, a second nurse (or pharmacist or other healthcare worker) goes through all the same steps that the first nurse did without knowledge of what result the first nurse got. He/she goes through all the steps needed to get the proper drug and dose to the correct patient, including doing any dosage calculations. He/she then compares the results of the calculation with that which had been done by the original nurse. If they do not match, reconciliation must take place until all agree on the correct drug and dose. All too often the calculations are done in conjunction with the second person, often resulting in both making the same mistakes. We wonder how often these independent double checks are being done incorrectly in our own hospitals. One of the RCA recommendations is auditing independent double checks for compliance and correctness.


The third major contributing factor was checking drug information in adult IV drug monograph rather than the pediatric one. This was enabled because the two monographs appeared in close proximity on the computer screen and, once selected, there were no readily visible markings that made the manual readily recognized as the adult manual. (Note the related recommendation we discussed in last week’s Patient Safety Tip of the Week appearing in “ISMP’s Guidelines for Standard Order Sets” to make sure that all order sets are clearly identifiable on all pages as “adult” or “pediatric”). This, of course, is another unintended consequence of technology. See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology:


And other contributory factors were present as well, such as pressure from the family to get pain relief promptly for their child.


The third RCA was on an azothioprine overdose. In this case, the medication reconciliation process failed. Numerous potential sources of information about the current home medications were available (eg. from the outpatient records and pharmacy of the hospital itself and from a provincial information network) yet none of these sources were accessed. Instead, information from the family was relied upon despite presence of a language barrier. The order for the azothioprine was provided by volume rather than actual dose. There was also no check of safe dose per weight conducted by either medicine, nursing or pharmacy. The original order also had some handwritten alterations rather than being rewritten (strikeouts and overwrites should not be allowed). And a written medication profile had not been given to the family to help them identify the drugs in question. Another contributory factor was that azothioprine was not a drug familiar to the staff on the hospital unit. This is a particularly good RCA for understanding many of the complexities involved in ordering medications for pediatric patients.


The last RCA involved administration of the wrong expressed breast milk (EBM). In fact, this was not a new problem at the hospital – it had occurred several times in the past at that hospital and another Alberta hospital. But the implementation of recommendations from the previous incidents was incomplete and there was a general lack of awareness of the potentially serious implications of such mixups on the part of both staff and families. Note that we previously discussed the issue of expressed breast milk mixups in our November 17, 2009 Patient Safety Tip of the Week “Switched Babies” and the Pennsylvania Patient Safety Authority issued a Patient Safety Advisory on Mismanagement of Expressed Breast Milk in 2007. Some of the recommendations in Alberta had been related to proper labeling of all breast milk, a double check/double sign procedure, and individual storage bins/trays appropriately labeled and stored in alphabetical order in the refrigerator. The patient name and number was to be verified and double checked before feeding EBM to infants. There was no evidence this was done. But there was also no visible prompt in the chart to remind staff that a double check was necessary. The RCA goes on to discuss a cogent point: education and information are much less powerful interventions than real-time reminders and checklists. Use of checklists for multiple steps in the whole EBM process would clearly have been valuable. Other contributing factors were newness of the healthcare provider to the unit and lack of standardization of the orientation for new staff.


We guarantee you that many of the contributing factors in these four incidents occur frequently at each of your institutions. You can clearly glean lessons from these RCA’s that are directly applicable in your own organizations. Why would we not want to share this sort of valuable information across all healthcare organizations? It is worthy noting that many of the publicly available RCA’s we mentioned come from countries that are not as litiginous as the United States (though it seems that public pressure may have played a role in the release of the Alberta RCA’s). The processes in these RCA’s and the lessons learned and the recommendations can be extremely important to all of you. But just telling these stories in your organizations significantly increases the likelihood that someone will remember one the next time they have to dispense a pediatric medicine or give expressed breast milk to a baby or put any substance into tubing. The only thing even more powerful in helping you remember them would be to hear the thoughts and feelings of the staff who were involved in these incidents. They are victims, too – victims of our system failures. How many of you are thinking now “that could have been me!”?





Health Quality Council of Alberta. Quality Assurance Review of the Three Medication and One Expressed Breast Milk Incidents at the Alberta Children’s Hospital, Calgary, Alberta. Public Report. March 17, 2010

ACH_Review_Public_Report_March_17_FINAL.pdf (application/pdf Object)



Pennsylvania Patient Safety Authority. Mismanagement of Expressed Breast Milk.

PA PSRS Patient Saf Advis 2007 Jun;4(2):46-50














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