Quality Improvement in Health Care (한국의료질향상학회지)

Korean Society for Quality in Health Care (한국의료질향상학회)
권호 표지
DOI QR코드

DOI QR Code

Development of Korean Root Cause Analysis Software for Analyzing Patient Safety Incidents

환자안전사건 분석을 위한 한글 근본원인분석 소프트웨어 개발

  • Choi, Eun-Young (Department of Preventive Medicine, University of Ulsan College of Medicine) ;
  • Lee, Hyeon-Jeong (Department of Preventive Medicine, University of Ulsan College of Medicine) ;
  • Ock, Min-Su (Department of Preventive Medicine, Ulsan University Hospital, University of Ulsan College of Medicine) ;
  • Lee, Sang-Il (Department of Preventive Medicine, University of Ulsan College of Medicine)
  • 최은영 (울산대학교 의과대학 예방의학교실) ;
  • 이현정 (울산대학교 의과대학 예방의학교실) ;
  • 옥민수 (울산대학교 의과대학 울산대학교병원 예방의학과) ;
  • 이상일 (울산대학교 의과대학 예방의학교실)
  • Received : 2017.12.05
  • Accepted : 2018.06.29
  • Published : 2018.06.30
Download PDF
⟨ Previous Next ⟩

Abstract

Purpose: The purpose of this study is to develop the Korean root cause analysis (RCA) software that can be used to systematically investigate underlying causes for preventing or reducing recurrence of patient safety incidents. Methods: We reviewed the existing guidelines and literatures on the RCA in order to figure out the RCA process. Also we examined the existing RCA softwares for investigating patient safety incidents to design the contents and interface of the RCA software. Based on the results of reviewing literatures and softwares, we developed a draft version of the Korean RCA software that can be easily used in Korean hospital settings by RCA teams. Results: The Korean RCA software consisted of several modules, which are modules for identifying patient safety incidents, organizing RCA team, collecting and analysing data, determining contributory factors and root causes, developing the action plans, and guiding evaluation. Conclusion: The Korean RCA software included optimized RCA process and structured logic for cause analysis. Thus even beginners in RCA are expected to easily use this software for investigating patient safety incidents. As software has been developed with the public financial support, it will be distributed free of charge. We hope that it will contribute to facilitating patient safety improvement activities in Korea.

Keywords

References

  1. Patient Safety Act Article 16 [Internet]. Sejong, Korea: National Law Information Center; 2017 [cited 2017 Feb 7]. Available from: http://www.law.go.kr/lsInfoP.do?lsiSeq=167782&efYd=20160729#0000
  2. Wachter RM. Patient safety at ten: unmistakable progress, troubling gaps. Health Aff (Millwood) 2010;29:165-73. https://doi.org/10.1377/hlthaff.2009.0785
  3. The Joint Commission. Root cause analysis in health care: tools and techniques. 5th ed. Illinois, USA: The Joint Commission Resources; 2015.
  4. Carroll JS, Rudolph JW, Hatakenaka S. Lessons learned from non-medical industries: root cause analysis as culture change at a chemical plant. Qual Saf Health Care. 2002;11(3):266-9. https://doi.org/10.1136/qhc.11.3.266
  5. Bagian JP, Lee C, Gosbee J, DeRosier J, Stalhandske E, Eldridge N, et al. Developing and deploying a patient safety program in a large health care delivery system: you can’t fix what you don’t know about. Jt Comm J Qual Improv 2001;27:522-32.
  6. National Health Service National Patient Safety Agency. Root Cause Analysis (RCA) investigation [Internet]. London, UK: NHS Improvement; 2017 [cited 2017 Nov 29]. Available from: http://www.nrls.npsa.nhs.uk/resources/collections/root-cause-analysis/
  7. Incident Analysis Collaborating Parties. Canadian Incident Analysis Framework [Internet]. Edmonton, AB: Canadian Patient Safety Institute; 2012 [cited 2017 Nov 29]. Available from: http://www.patientsafetyinstitute.ca/en/toolsResources/IncidentAnalysis/Documents/Canadian%20Incident%20Analysis%20Framework.PDF
  8. Braithwaite J, Westbrook MT, Mallock NA, Travaglia JF, Idedma RA. Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement program. Qual Saf Health Care. 2016;15(6):393-9. https://doi.org/10.1136/qshc.2005.017525
  9. Wu AW, Lipshutz AK, Pronovost PJ. Effectiveness and efficiency of root cause analysis in medicine. JAMA. 2008;13(6):685-7.
  10. Ministry of Health and Welfare. Korean Institute for Healthcare Accreditation. 2016 the Act on Patient Safety practice manual. Seoul, Korea: Korean Institute for Healthcare Accreditation; 2016.
  11. Shin HH. Investigation and promotion of patient safety actions at medical institutions. Seoul, Korea: Korean Institute of Hospital Management; 2015.
  12. Choi EY. Experiences of Patient Safety Managers in Root Cause Analysis in Korea [dissertation]. Ulsan: Ulsan University; 2017.
  13. Choi EY, Lee HJ, Ock M, Jo MW, Lee SI. Comparison of Root Cause Analysis Software for Investigating Patient Safety Incidents. Qual Improv Health Care. 2017;23(1):11-23. https://doi.org/10.14371/QIH.2017.23.1.11
  14. Veterans Administration National Center for Patient Safety. Root cause analysis tools. Root cause analysis (RCA) step-by-step guide [Internet]. Washington DC, USA: US Department of Veterans Affairs; 2017 [cited 2017 Nov 29]. Available from: https://www.patientsafety.va.gov/docs/joe/rca_step_by_step_guide_2_15.pdf
  15. National Patient Safety Foundation. Improving root cause analysis and actions to prevent harm [Internet]. Boston, USA: National Safety Foundation; 2015 [cited 2017 Nov 29]. Available from: http://www.ihi.org/resources/Pages/Tools/RCA2-Improving-Root-Cause-Analyses-and-Actions-to-Prevent-Harm.aspx
  16. Imperial College London. Systems Analysis of Clinical Incidents: The London Protocol [Internet]. London, UK: Imperial College London; 2017 [cited 2017 Nov 29]. Available from: http://www.imperial.ac.uk/media/imperial-college/medicine/surgery-cancer/pstrc/londonprotocol_e.pdf
  17. Kawano R. Improvement for medical System by Analyzing Fault root in human ERror incident. Lee MJ, translator. Seoul, Korea: HanEon; 2014.
  18. Lee HY, Choi EY, Ock M, Lee SI. Guidelines for Performing Root Cause Analysis. Qual Saf 2017;23(1):25-39.
  19. $TapRooT^{(R)}$ homepage [Internet]. Tennessee, USA: TapRoot; 2017 [cited 2017 Mar 24]. Available from: http://www.taproot.com/
  20. Apollo Root Cause $Analysis^{TM}$ homepage [Internet]. Ocean Grove, Australia; Apollo Root Cause Analysis; 2017 [cited 2017 Mar 24]. Available from: http://www.realitycharting.com/
  21. Reliability Center Inc. $PROACT^{(R)}$ Root Cause Analysis homepage [Internet]. Virginia, USA: Reliability Center Inc.; 2017 [cited 2017 Mar 24]. Available from: http://www.reliability.com/index.html
  22. Outcome Engenuity homepage [Internet]. Minnesota, USA: Outcome Engenuity; 2017 [cited on 2017 Mar 28]. Available from: https://www.outcome-eng.com/
  23. Think Reliability homepage [Internet]. [cited on 2017 Mar 28]. Available from: https://www.thinkreliability.com/
  24. Rooney JJ, Heuvel LNV. Root cause analysis for beginners. Quality Progress. 2004;37(7):46-53.
  25. Taitz J, Genn K, Brooks V, Ross D, Ryan K, Shumack B, et al. System-wide learning from root cause analysis: a report from the New South Wales Root Cause Analysis Review Committee. Qual Saf Health Care. 2010;19(6):e63.
  26. Hirsch KA, Wallace DT. Software facilitation of root cause analysis in healthcare organizations. J Healthc Risk Manag. 2000;20(1):32-5. https://doi.org/10.1002/jhrm.5600200106
  27. Hussin H, Ahmed U, Muhammad M. Critical success factors of root cause failure analysis. Indian J Sci Technol. 2016;9(48):1-10.
  28. Shin HH. Investigation and promotion of patient safety actions at medical institutions. Seoul, Korea: Korean Institute of Hospital Management; 2015.