ABSTRACT
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.
