Department of Health Sciences, Ålesund, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Larsgårdsvegen 2, Ålesund, 6025, Norway.
Faculty of Health Sciences and Social Care, Molde University College, PO. Box 2110, Molde, 6402, Norway.
BMC Health Serv Res. 2023 Nov 8;23(1):1224. doi: 10.1186/s12913-023-10178-3.
Root cause analysis (RCA) is a systematic approach, typically involving several stages, used in healthcare to identify the underlying causes of a medical error or sentinel event. This study focuses on how members of a Norwegian RCA team experience aspects of an RCA process and whether it complies with the Norwegian RCA method.
Based on a sentinel event in which a child died unexpectedly during childbirth in a Norwegian hospital in 2021, the following research questions are addressed: 1. What was the RCA team's experience of the RCA process? 2. Was there compliance with the Norwegian RCA method in this case? A case study was chosen out of the desire to understand complex social phenomena and to allow in-depth focus on a case.
The result covered three main themes. The first theme related to the hospital's management system and aspects of the case that made it challenging to follow all recommendations in the Norwegian RCA guidelines. The second theme encompassed external and internal assessment. The RCA team was composed of members with methodological and medical expertise. However, the police's involvement in the case made it complex for the team to carry out the process. The third and final theme covered intrapersonal challenges RCA team members faced. Team members experienced various challenges during the RCA process, including being neutral, dealing with role-related challenges, grappling with ambivalence, and managing the additional time burden and resource constraints. As anticipated in the RCA guidelines, the team's ability to remain neutral was tested.
The findings of this study can help stakeholders better comprehend how an inter-professional RCA teamwork intervention can affect a healthcare organization and enhance the teamwork experience of healthcare staff while facilitating improvements in work processes and patient safety. Additionally, these results can guide stakeholders in creating, executing, utilizing, and educating others about RCA processes.
根本原因分析（RCA）是一种系统方法，通常涉及几个阶段，用于医疗保健领域，以确定医疗错误或警戒事件的根本原因。本研究重点关注挪威 RCA 团队成员在多大程度上体验 RCA 过程的各个方面，以及该过程是否符合挪威 RCA 方法。
基于 2021 年挪威一家医院在分娩期间一名儿童意外死亡的警戒事件，提出了以下研究问题：1. RCA 团队对 RCA 过程的体验是什么？2. 在这种情况下，是否符合挪威 RCA 方法？选择案例研究是出于对理解复杂社会现象的渴望，并允许对案例进行深入关注。
结果涵盖了三个主要主题。第一个主题涉及医院的管理系统和案例的某些方面，这些方面使得难以遵循挪威 RCA 指南中的所有建议。第二个主题包括外部和内部评估。RCA 团队由具有方法学和医学专业知识的成员组成。然而，警方参与该案使得团队难以开展该过程。第三个也是最后一个主题涵盖了 RCA 团队成员面临的个人挑战。团队成员在 RCA 过程中面临各种挑战，包括保持中立、应对与角色相关的挑战、应对矛盾心理以及管理额外的时间负担和资源限制。正如 RCA 指南所预期的那样，团队保持中立的能力受到了考验。
本研究的结果可以帮助利益相关者更好地理解跨专业 RCA 团队合作干预如何影响医疗保健组织，并增强医疗保健人员的团队合作体验，同时促进工作流程和患者安全的改进。此外，这些结果可以为利益相关者创建、执行、利用和教育他人有关 RCA 流程提供指导。
