A cross-sectional study on the relationship between utilization of root cause analysis and patient safety at 139 Department of Veterans Affairs medical centers.

BACKGROUND: Empirical evidence is limited that root cause analysis (RCA), an event analysis tool used in health care to evaluate the systemic factors that lead to adverse events, improves patient safety. A cross-sectional study was conducted to examine the relationship between RCA and patient safety. METHODS: RCA data were collected for the 139 Department of Veteran Affairs medical centers (VAMCs) in the National Center for Patient Safety database from 2004 through 2006. Participants were divided into three RCA utilization categories on the basis of their yearly RCA rate: (1) fewer than 4 RCAs, (2) 4 to 5 RCAs, and (3) 6 or more RCAs per year. An analysis of variance was conducted of each Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) across the three RCA utilization categories. RESULTS: Facilities completed between 3 and 59 RCAs in the three-year period (mean RCA utilization rate, 4.86 RCAs per year). In this period, RCA actions by facility ranged from 9 to 323 (mean, 28 actions per year per facility). Mean patient-days of care, facility budget, surgical volume, and the number of strong improvement actions were significantly different across RCA utilization categories. The mean rates of PSI 9 (Postoperative Hemorrhage or Hematoma), PSI 10 (Postoperative Physiologic and Metabolic Derangements), and PSI 13 (Postoperative Sepsis) were significantly different across RCA utilization categories. CONCLUSIONS: Large, high-spending VAMCs conduct more RCAs per year than smaller, low-spending facilities. VAMCs that do more RCAs develop more corrective actions. VAMCs that complete fewer than four RCAs per year have higher rates of postoperative complications. It is unclear if RCAs are associated with a functional patient safety program or directly improve patient safety.

Code debriefing from the Department of Veterans Affairs (VA) Medical Team Training program improves the cardiopulmonary resuscitation code process.

A Department of Veterans Affairs (VA) medical center developed a brief questionnaire to support the identification of issues and the continuous improvement of the cardiopulmonary resuscitation process and its outcomes.

Medical team training and coaching in the Veterans Health Administration; assessment and impact on the first 32 facilities in the programme.

BACKGROUND: Communication is problematic in healthcare. The Veterans Health Administration is implementing Medical Team Training. The authors describe results of the first 32 of 130 sites to undergo the programme. This report is unique; it provides aggregate results of a crew resource-management programme for numerous facilities. METHODS: Facilities were taught medical team training and implemented briefings, debriefings and other projects. The authors coached teams through consultative phone interviews over a year. Implementation teams self-reported implementation and rated programme impact: 1='no impact' and 5='significant impact.' We used logistic regression to examine implementation of briefing/debriefing. RESULTS: Ninety-seven per cent of facilities implemented briefings and debriefings, and all implemented an additional project. As of the final interview, 73% of OR and 67% of ICU implementation teams self-reported and rated staff impact 4-5. Eighty-six per cent of OR and 82% of ICU implementation teams self-reported and rated patient impact 4-5. Improved teamwork was reported by 84% of OR and 75% of ICU implementation teams. Efficiency improvements were reported by 94% of OR implementation teams. Almost all facilities (97%) reported a success story or avoiding an undesirable event. Sites with lower volume were more likely to conduct briefings/debriefings in all cases for all surgical services (p=0.03). CONCLUSIONS: Sites are implementing the programme with a positive impact on patients and staff, and improving teamwork, efficiency and safety. A unique feature of the programme is that implementation was facilitated through follow-up support. This may have contributed to the early success of the programme.

Use of the Safety Attitudes Questionnaire as a measure in patient safety improvement.

BACKGROUND: There is widespread interest in improving safety for patients receiving medical care, yet direct measurement of harm has been elusive. The Safety Attitudes Questionnaire is a validated measure of patient safety culture that has been associated with improved patient outcomes. We report on an attempt to use the Safety Attitude Questionnaire as an outcome measure for a patient safety implementation project. METHODS: Operating room staffs at 63 Veterans Affairs Medical Centers were surveyed using the Safety Attitude Questionnaire before and after a medical team training (MTT) program focused on improving staff communication. Survey results before and after MTT within medical centers were compared using nonparametric statistical testing. RESULTS: Of the 63 VA hospitals that received medical team training, 26 showed changes in the staff's attitude as measured by the Safety Attitudes Questionnaire. Improvement was most common in the "perceptions of management" domain. There was no correlation between survey response rate and measured improvement. CONCLUSIONS: The Safety Attitudes Questionnaire demonstrated good utility as a possible proxy measure of patient safety in the implementation study of MTT. Health care organizations may consider using it to measure effectiveness of safety improvement activities.

The effectiveness of root cause analysis: what does the literature tell us?

BACKGROUND: Root cause analysis (RCA) is an analysis framework used in health care to determine the systemic causes and prevent recurrences of adverse events. It is required by The Joint Commission for reported events and by the Department of Veterans Affairs (VA) National Center for Patient Safety for qualifying events in VA medical centers. The evidence on RCA effectiveness in improving patient safety was reviewed. METHODS: MEDLINE, Academic Search Premier, and the Cochrane Database were searched from database inception to September 2007. RCA case studies and articles that directly addressed the RCA framework were reviewed. RESULTS: Discussion of RCA did not emerge in the literature until the late 1990s, and there have been no controlled trials that test the RCA framework. Twenty-three articles describe the RCA process, 38 articles present RCA case studies, and 12 articles analyze weaknesses of the RCA framework. Eleven of the case studies measure RCA effectiveness, 3 using clinical outcome measures and 8 using process measures. All 11 articles report improvement of safety following RCA. RCA participants report the difficulty in forming causal statements and in developing/implementing corrective actions. Criticisms of RCA include the uncontrolled study design and participant biases. DISCUSSION: Overall, the limited literature on RCA effectiveness provides anecdotal evidence that RCA improves safety. At the same time, it highlights the numerous theoretical problems with the analytical framework. Formal studies at the system level and cost-benefit analysis are needed to determine the effectiveness of RCA. Structured publication of case studies will support shared knowledge and will provide benchmarks for improvement. Enrichment of the RCA literature body will enable reproducibility of improvement work, optimization of analysis, and validation of the framework itself.

Resolvin E2: identification and anti-inflammatory actions: pivotal role of human 5-lipoxygenase in resolvin E series biosynthesis.

The family of resolvins consists of omega-3 fatty acid-derived mediators, including E series resolvins generated from eicosapentaenoic acid (EPA), and carry potent anti-inflammatory properties. Here, we report the isolation, identification, and bioactions of resolvin E2 (RvE2), which is 5S,18-dihydroxy-eicosapentaenoic acid. RvE2 stopped zymosan-induced polymorphonuclear (PMN) leukocyte infiltration and displayed potent anti-inflammatory properties in murine peritonitis. We also demonstrate that human recombinant 5-lipoxygenase generates RvE2 from a common precursor of E series resolvins, namely, 18-hydroxyeicosapentaenoate (18-HEPE). Furthermore, the initial 5-hydroperoxide intermediate was also converted to a 5(6)-epoxide intermediate in RvE1 formation. These results demonstrate that RvE2, together with RvE1, may contribute to the beneficial actions of omega-3 fatty acids in human diseases. Moreover, they indicate that the 5-lipoxygenase in human leukocytes is a pivotal enzyme that can produce both pro- and anti-inflammatory chemical mediators.