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When a significant patient care error occurs it is important to quickly gather all the pertinent facts and the full spectrum of causal factors when they are still fresh in everyone's memory. To acquire needed information, investigators should examine evidence collected from the scene of the event, witness statements, interviews, and documents. This inquiry should answer questions regarding "what," "when," "where," "who," and "how."
While each undesirable event does not need a formal root cause analysis, all reported incidents should be evaluated by the line manager or supervisor to identify the causes. What's important in an incident investigation is that physicians, managers and staff use a logical thought process to arrive at the most probable cause of the event. The following set of questions can be incorporated into your organization's root cause analysis model as guidelines for all problem inquiries.
Quite often, the problem is misstated, obscured, or the real fault is disguised. By objectively describing the events leading up to the incident, you can be assured you're working on the right problem.
Once again, as in Question 1, the effects may be camouflaged. It is not unusual for the effect of a problem to be understated.
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Opinions expressed in "Sound olf" may be edited and are not necessarily those of' ASHRM or the American Hospital