Hibbert Peter D, Thomas Matthew J W, Deakin Anita, Runciman William B, Braithwaite Jeffrey, Lomax Stephanie, Prescott Jonathan, Gorrie Glenda, Szczygielski Amy, Surwald Tanja, Fraser Catherine
Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Macquarie University, New South Wales 2109, Australia.
Centre for Population Health Research, Sansom Institute for Health Research, University of South Australia, GPO Box 2471, Adelaide, South Australia 5001, Australia.
Int J Qual Health Care. 2018 Mar 1;30(2):124-131. doi: 10.1093/intqhc/mzx181.
To assess the strength of root cause analysis (RCA) recommendations and their perceived levels of effectiveness and sustainability.
All RCAs related to sentinel events (SEs) undertaken between the years 2010 and 2015 in the public health system in Victoria, Australia were analysed. The type and strength of each recommendation in the RCA reports were coded by an expert patient safety classifier using the US Department of Veteran Affairs type and strength criteria.
Thirty-six public health services.
MAIN OUTCOME MEASURE(S): The proportion of RCA recommendations which were classified as 'strong' (more likely to be effective and sustainable), 'medium' (possibly effective and sustainable) or 'weak' (less likely to be effective and sustainable).
There were 227 RCAs in the period of study. In these RCAs, 1137 recommendations were made. Of these 8% were 'strong', 44% 'medium' and 48% were 'weak'. In 31 RCAs, or nearly 15%, only weak recommendations were made. In 24 (11%) RCAs five or more weak recommendations were made. In 165 (72%) RCAs no strong recommendations were made. The most frequent recommendation types were reviewing or enhancing a policy/guideline/documentation, and training and education.
Only a small proportion of recommendations arising from RCAs in Victoria are 'strong'. This suggests that insights from the majority of RCAs are not likely to inform practice or process improvements. Suggested improvements include more human factors expertise and independence in investigations, more extensive application of existing tools that assist teams to prioritize recommendations that are likely to be effective, and greater use of observational and simulation techniques to understand the underlying systems factors. Time spent in repeatedly investigating similar incidents may be better spent aggregating and thematically analysing existing sources of information about patient safety.
评估根本原因分析（RCA）建议的力度及其感知到的有效性和可持续性水平。
对2010年至2015年期间在澳大利亚维多利亚州公共卫生系统中开展的所有与哨兵事件（SEs）相关的RCA进行分析。RCA报告中每项建议的类型和力度由一名专家患者安全分类员根据美国退伍军人事务部的类型和力度标准进行编码。
36个公共卫生服务机构。
被归类为“强”（更有可能有效且可持续）、“中”（可能有效且可持续）或“弱”（不太可能有效且可持续）的RCA建议的比例。
在研究期间有227项RCA。在这些RCA中，共提出了1137项建议。其中8%为“强”建议，44%为“中”建议，48%为“弱”建议。在31项RCA中，即近15%，仅提出了弱建议。在24项（11%）RCA中，提出了五项或更多弱建议。在165项（72%）RCA中，未提出强建议。最常见的建议类型是审查或加强政策/指南/文件以及培训与教育。
维多利亚州RCA产生的建议中只有一小部分是“强”建议。这表明大多数RCA的见解不太可能为实践或流程改进提供信息。建议的改进措施包括在调查中增加人为因素专业知识和独立性，更广泛地应用现有工具以帮助团队对可能有效的建议进行优先排序，以及更多地使用观察和模拟技术来理解潜在的系统因素。反复调查类似事件所花费的时间，或许更好地用于汇总和专题分析有关患者安全的现有信息来源。
