Medical adverse events: Root cause analysis of 16 reports from a teaching hospital

Abstract

Objective: One of the most important concerns in health care systems is the patient safety. The root cause analysis (RCA) is a systematic process for identifying root causes and contributing factors of problems or events. The objective of this study was to review RCA reports for determining factors contributing to adverse events through an organizational perspective. Methods: this study was conducted in a tertiary care teaching hospital in 2014. The process of root cause analysis was taken from the London Protocol of NHS. We calculated descriptive statistics to determine the effect size frequency. Results: Reviewing process of 16 adverse events identified 38 care or service delivery problems, which showed 317 contributing factors and underlying causes. Accordingly, the most important contributing factors were identified: task factors (20%), education and training factors (16%), communication factors (14%) and team and social factors (13%). Conclusion: Negligence of clinical guidelines and instructions, inappropriate supervision and guidance, lake of communication skills and issues related to organizational culture were the main underlying factors that contributed to medical adverse events.

Keywords

• rca
• contributory factors
• adverse events