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institutional review board, and the faculty National Surgical Quality Improvement
Project director. Progress reports and results were then presented at a departmen-
tal conference. The authors noted that this bottom-up approach gave the residents
greater ownership over problems that they identified and areas that were of inter-
est to them. They also noted that this kind of approach to implementation of a QI
program requires institutional buy-in and initially may be difficult to engage
administrators.
Root Cause Analysis
Root cause analysis (RCA) is a structured systematic approach used to investigate
the various factors that led to a patient safety incident or adverse event [ 2 ]. The
origins of the RCA technique stem from its use in the engineering industry as a
method of identifying systems-problems that result in underperformance, variations
in production processes, and design failures [ 1 ]. Its use in healthcare began in the
1990s as a method to establish the “what, how, and why” of patient safety incidents.
An RCA is generally performed by a multidisciplinary team using one of the fol-
lowing problem-solving techniques: Five Whys analysis, Pareto analysis, or fault
tree analysis, among others [ 65 , 77 , 81 ]. It is best utilized to retrospectively review
an adverse event to determine the sequence of events and the systemic factors that
led to the undesired event and can be integrated with other QI tools. Several institu-
tions have reported using RCA in their morbidity and mortality conferences [ 5 , 66 ,
71 ], as it lends itself to retrospectively review adverse events. The Veterans Affairs
National Center for Patient Safety has a detailed step-by-step guide on how to per-
form an RCA that may be found online [ 76 ].
Five Whys Analysis
The Five Whys approach is a method intended to progressively delve deeper into
why an adverse event occurred with each subsequent why, until the root of a prob-
lem is identified [ 66 ]. Once the initial problem is specified, a consecutive series of
why questions are asked, with each answer becoming the subject of the next ques-
tion. Each subsequent response should generate a more profound investigation, and
potential improvement strategies are identified. See Fig. 11.3 for an example of the
application of the Five Whys in a situation where a patient who should have been
ordered for venous thromboembolism (VTE) prophylaxis is diagnosed with a pul-
monary embolism.
This example identifies several errors in the system including the lack of inclu-
sion of VTE chemoprophylaxis in standard order sets. While exclusion of VTE che-
moprophylaxis in the patient’s orders was due to a human error by the resident who
forgot to include it, if the standard of care is for all postoperative patients at risk for
a VTE to be administered with VTE chemoprophylaxis, then it should be included
in all order sets. Additionally, the healthcare organization may consider adding an
automated alert to all providers caring for postoperative patients to confirm whether
or not their patient should be on VTE chemoprophylaxis.
S. Helo and C. Welliver