Experience feedback committees: A way of implementing a root cause analysis practice in hospital medical departments.

Abstract

BACKGROUND:The experience feedback committee (EFC) is a tool designed to involve medical teams in patient safety management, through root cause analysis (RCA) within the team. OBJECTIVES:To investigate the functioning of EFCs in the departments of a large university-affiliated hospital in France and to consider its potential contribution to the management of patient safety. METHODS:Cross-sectional, observational study, based on an analysis of the documents produced by the EFCs for 1 year. Data were collected independently by two investigators in meeting minutes, adverse event reports and event analysis reports. RESULTS:The study included all 20 EFCs operating in the hospital's medical departments. During the study year, committees held 164 meetings, reviewed 1707 adverse events, conducted 91 event analyses and decided on 206 corrective actions. The median number of corrective actions adopted by each EFC was five actions (range, 0-62). A root cause analysis (RCA) was present in 76% of the analysis reports, and these analyses were complete in only 23% of the reports. There was also a lack of planning corrective actions: an implementation deadline was only defined in 26% of the actions. CONCLUSIONS:Healthcare professionals adhered to the system-based approach to patient safety, but we observed difficulties in holding regular meetings and deviations from the theoretical framework. These findings confirm the difficulties of practicing RCA in the healthcare setting. Nevertheless, EFCs can be vectors of safety culture and teamwork.