The Daily Dose • Monday, April 30

The Role of Culture for Effective Use of Safety Reporting, Checklists, and Root Cause Analysis

By Dr. Michael D. McDonald, from the IARS 2018 Annual Meeting*

During this review session, Dr. Jonathan Cohen describes how safety culture plays a role in the effective use of safety reporting, checklists, and root cause analysis. Dr. Cohen discussed the role of each and challenges that accompany their effective use. Safety reporting, checklists, and root cause analysis all have roles in medicine, however as a field we are doing a poor job using them as effectively as we can.

Safety reporting has its origin in aviation. A safety report should be a brief, factual report with the goal of capturing safety events, analyzing the data, and disseminating information in healthcare to facilitate change and improvement in care delivery. The field of medicine currently struggles with analyzing data and disseminating results, and fundamental aspects of successful reporting have been misunderstood and misinterpreted. Safety reports should not be punitive nor place blame. The goal of such a report should be to describe the event to give direction for further analysis. The end result should be to inform those who can adequately address the issue and result in corrective action. Too often a safety report results in superficial responses, such as attributing events to human error, or result in premature closure by with a “we’ll look into it” statement. Safety reporting also should not be a way of tracking incidence and there is a dichotomy in that officers cannot be pleased with both increasing and decreasing number of incident reports and that reporting rates are not determined by incidence but instead social, cognitive, and organizational factors.

Checklists have the potential to aid in decreasing critical mistakes. The impact of checklists varies with the effectiveness of their implementation, and their implementation can be challenging. Checklists should include a few key components to be effective: short with critical elements only, done the same way every time, include closed loop communication, and include an appropriate checklist leader. When they fail, it is often a result of compliance, which is intrinsically tied to the checklist design. Design and implementation requires a focused approach with involvement of leaders in administration, such as the Chief Medical Officer. Those who are skeptical should be paid attention as conversion of these individuals is critical for successful implementation. Setbacks should be expected, and it is important to realize the work will never be complete.

Root cause analysis can be a successful tool to improving safety, however more often than not it is done incorrectly. First, it is often done to satisfy regulatory bodies rather than because it is the right thing to do. Further, it often identifies superficial and easy fixes rather than the more costly systemic changes that are often required to result in real improvement. Too frequently does analysis lack learning and action afterwards, and this should be focused on to improve efficacy.

Successful use and implementation of safety reporting, checklists, and root cause analysis all goes back to safety culture. In order to improve their function, the culture of an institution must change to achieve real results. However, changing culture is not an intervention on its own but an outcome. Changing culture is very challenging, but there have been advances in different approached to achieve change. One approach is described as safety anarchy, where we attempt to shift safety culture to practice safety because it is the right thing to do instead of because a governing body tells us so. This approach works to replace hierarchy with local ownership, collaboration, and autonomy. A second approach is via a Safety-II approach where focus is shifted toward identifying what makes things go right more often than not, compared to the current Safety-I model of working backwards to prevent things that go wrong. Finally, focusing on cultivating an environment where employees find joy in work. People who find joy and meaning in their work, work harder, smarter, and make less mistakes.

In summary, while we currently use safety reporting, checklists, and root cause analysis in medicine, we often do so incorrectly and inefficiently. To improve their effectiveness, we must focus on cultivating a safety culture that supports their use to identify safety events, analyze data, and facilitate change to improve safety.

*Coverage of the Review Course Learning session, Safety Reporting, Checklists, and Root Cause Analysis: What Are They Good For? Absolutely Nothing?

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