Adapting root cause analysis to chronic medical conditions.

BACKGROUND: Root cause analysis (RCA), used to study the conditions leading to acute accidents, was adapted to analyze adverse events in chronic medical conditions. METHODS: RCA was modified to investigate "trigger events"--markers of potential adverse events--in outpatient diabetes care. For 20 cases with the trigger event of hypoglycemia evidenced by an A1C of > or = 11%, a multidisciplinary team reviewed the findings of medical record abstractions, provider interviews, and patient interviews for each case. The RCA team identified active failures, error-producing conditions, latent conditions, and defenses leading to the trigger event in each case. RESULTS: The methodology identified potential root causes of persistent hyperglycemia. Latent conditions, error-producing conditions, and active failures occurred at the assessment, planning, and implementation phases of a diabetes visit. Recurring failure modes were identified within and across cases. CONCLUSION: RCA can be used to study trigger events in medical care for chronic conditions. Although the data collection occurs months after the event, this methodology can identify variations in chronic care and stimulate discussion about potential solutions.

Documentation of competency: Maintaining an outcomes database.

Medical practice in the 21st century will include increased scrutiny of the competency of vascular surgeons measured in large part by treatment outcomes. At least part of the drive behind this is that the public demand for clinical competency of its doctors is greater than ever as the unassailable position of the "all-knowing physician" is (appropriately) vanishing. Two general types of variables need to be considered in the assessment of treatment outcomes: key outcome variables and key process variables. Key outcome variables are the critical results from a treatment plan, whereas key process variables affect these results. Ideal tracking methods do not exist in most hospital systems, and many variables are out of the control of the individual surgeon. Difficulties recording and reporting outcomes and determining competencies are numerous, but vascular surgeons must accept and overcome these difficulties. Standardized definitions for preoperative, surgical, and postoperative variables as well as treatment results must be decided before attempting to determine competency. Once the variables and definitions to define competency are determined, commercially available computer software can make the task of data recording and data output realistic. Eventually, systemwide "enterprise" solutions from computer companies will make this task even more uncomplicated.