Steps to a Safer
Work Environment
Safety in the workplace is
something that everyone
has to think about. Delays &
errors can have a significant
impact on patient safety.
 Get everyone invested.
Set goals. It’s an
excellent way to
establish accountability,
compliance, and interest
in ongoing safety.
 Ask questions if you
have doubts or concerns
and make sure you
understand the answers.
 Report patterns of
concerning behavior by
individuals or
institutions that care for
transplant patients.
Did You Know?
Top 5 policy issues
identified during
UNOS Site Surveys:
1. Documenting
Patient Notification
2. Documenting ABO
verification before
transplant
In this issue of the OPTN/UNOS Operations and Safety’s newsletter, we will help you identify
potential patient safety events in your facility, give you practical tools to help you correct
your safety issues, and highlight effective practices that others have put in place for related
events.
What Happened and Why? Getting to the Root of the Problem.
When something goes wrong and patient safety is jeopardized, you need to identify the root
cause of the problem and isolate what you can learn from the experience. Research studies
have shown that patient safety issues within organizations are related to problems with
processes and systems in about 95% of the cases and to personnel problems only 5% of the
time. Yet, most organizations spend more time trying to identify who was at fault instead of
focusing on why it happened in the first place. Generally speaking, most errors are the result
of a system failure and not an individual’s mistake.
The complexity of busy transplant programs and procurement organizations can make it
difficult for you to isolate the root cause of an event. Looking for the root cause of an event
is not unlike assessing and evaluating the cause of a patient’s symptoms. Shortness of
breath and extreme fatigue are symptoms. Treating the symptoms alone will not resolve
the underlying problem but using tests and health assessments will help you determine the
root or cause of the problem. This is similar to investigating the cause of a medical error or
system failure. You need to identify the problem first, and then drill down to assess and
evaluate the situation more thoroughly, which allows you to develop a corrective action
plan.
Patient safety issues tend to reoccur and may impact new individuals who aren’t aware
that this particular patient safety issue has occurred before. If a patient safety issue either
occurs frequently or has significant negative impact, and requires many resources or staff
time to fix, root cause analysis (RCA) can be of significant help.
What is Root Cause Analysis?
RCA is a tool to help you identify not only what and how an event occurred, but also why it
happened. Only after investigators have determined why an event or failure occurred, can
they implement corrective measures to prevent the event from happening again. If you
perform an RCA correctly, you should be able to identify primary and secondary causes of
the event.
3. ABO typing X 2 prior
to listing candidates
4. Data entry errors of
candidate status or
errors in
documenting status
5. Not removing
recipients from the
waiting list within
24 hours of
transplant.
Conditions
SAFETY EVENT
Catalyst
There are always at least two causes. Define the problem not the symptom. Understanding
why an event occurred is the key to developing effective action plans to prevent future
occurrences. Continue to ask “why”, until the question is answered. Be careful with asking
“who” as fear may lead to not addressing the problem well. A timeline of circumstances
leading up to the event can help you identify conditions of the event and any catalyst. Imagine the
following scenario:
The Washington Monument is deteriorating and investigators ask why. They learn that harsh chemicals are
used to clean the monument, which contributes to its deterioration. To probe deeper, investigators ask
why the harsh chemicals are used. The cleaning crew responds that they use the chemicals to clean up a
significant amount of bird droppings. To probe further, investigators ask why so many birds gather around
the monument. They discover that the birds are there to eat spiders. This continued line of questioning
reveals that the spiders are drawn to the monument because of the large gnat population and spiders eat
gnats. In their final line of questioning, investigators learn that the lights used around the monument
attract gnats. Ultimately, investigators determine that turning the lights on one half hour later than dusk
can solve the issue altogether. This process utilizes the Six Sigma approach of the 5 Whys: Keep asking
why until you have identified potential causes.
Tools and Resources
An RCA typically involves several steps and, according to the Joint Commission, may have more than one
root cause to analyze. The process for determining a root cause analysis needs to begin as soon as an event
or near miss occurs. Steps may include:
1. Defining the problem - what is the fundamental reason for a failure or process error?
2. Listing all possible causes and a timeline of the event
3. Identifying if there have been prior occurrences and document what has changed;
4. Continuing to ask why until the root cause is identified - look for points in the process where you can
implement change
5. Brainstorming for solutions - policy changes, staff education, revised forms, etc
6. Developing a corrective action plan
7. Communicating results of the investigation to everyone involved
8. Ensuring effectiveness of action plans through internal observations and audits
Several tools are available to help your organization conduct a thorough RCA and action plans. You can find
many of these tools in the Root Cause Analysis Handbook. 1 UNOS has also developed a template to help
transplant centers and OPOs create effective Corrective Action Plans (CAP) when policy violations are
identified. Access this and other resources now. Don’t forget that the UNOS library is also available to
members for customized literature searches of various databases, including the National Library of
Medicine's MEDLINE database, using PubMed. Contact the UNOS Librarian at [email protected].
Share Your Effective Practices
Use UNetSM to share your effective practices so others may learn from your experiences. The Operations and
Safety Committee will review your submissions to glean important process insights and share them through
the monthly Member e-Newsletter. Visit our resource page for some recently shared guidance and effective
practices.
Watch for these topics in the upcoming newsletter:
Developing and Implementing Corrective Actions
Measuring the Effectiveness of Corrective Actions & Developing Preventative Action Plans
1
Root Cause Analysis Handbook: A Guide to Effective Investigation, ABSG Consulting Inc., 1999.
Marx, David. “Maintenance Error Causation.” A technical report prepared for the Federal Aviation Administration; June 9, 1999
Sentinal Event Data: Root Causes by Event type: The Joint Commission, 2011.
http://www.jointcommission.org/assets/1/18/se_root_cause_event_type_2004_2Q2011.pdf Accessed August 8, 2011
Ideas, Questions, or Concerns? Please Contact: Kimberly Taylor, RN, Senior Patient Safety Specialist, Liaison
to the Operations and Safety Committee at 804-782-4098 or [email protected].