SummaryChildren's Hospital of Philadelphia annually reviews all findings from root cause analyses of serious safety events, with the goal of identifying and addressing systemwide vulnerabilities. Known as common cause analysis, this review identifies common themes from the many recommended changes produced by root cause analysis findings. Once identified, themes are prioritized based on frequency of occurrence and professional judgment. Children's Hospital of Philadelphia's safety team then works with senior hospital leaders to correct vulnerabilities. While a formal evaluation of the program has not been conducted, anecdotal reports suggest that it has allowed the hospital to identify and address important safety problems, has enhanced the quality of communication about safety issues with organizational leaders, and has contributed to a significant reduction in the hospital's serious safety event rate.
See the Description for information about executive sponsor participation on the analysis team, use of a database to track events, and new processes for annual common cause analysis, prioritizing themes, developing safety initiatives to correct vulnerabilities, and analysis of less serious events; the Results section for information about improved effectiveness of communication and contribution to a decline in the serious safety event rate; the Planning and Development section for information about enhancements to the process; the Resources section for updated staffing numbers; and the Adoption Considerations section for additional insights into sustaining the process through better communication (updated November 2012).Suggestive: The evidence consists of post-implementation reports about the ability of common cause analysis to identify patient safety and outcome vulnerabilities and to spur organizational action and support in addressing these vulnerabilities.
Developing OrganizationsChildren's Hospital of Philadelphia
Date First Implemented2006
Age > Child (6-12 years); Vulnerable Populations > Children; Age > Fetus; Infant (1-23 months); Newborn (0-1 month); Preschooler (2-5 years)
Problem AddressedRoot cause analysis is widely used to identify the underlying causes of medical errors. Exclusive reliance on root cause analyses, however, can result in a lengthy list of action items (too many to be addressed) and the failure to get an accurate view of the "big picture"—common themes and issues affecting safety.
- Lengthy list of action items: Organizations that conduct many root cause analyses can become overwhelmed with a long list of recommended improvement actions. Changes that would have benefited patient safety may not be implemented because staff deem other changes a higher priority or move on to address more recent events.1
- Lack of big-picture view: An individual root cause analysis may not reveal safety themes that affect multiple hospital departments or aspects of care. As a result, corrective changes may be applied narrowly, even when broader application could have a greater impact on patient safety.1
Description of the Innovative ActivityChildren's Hospital of Philadelphia conducts a root cause analysis after every serious safety event. The hospital then annually reviews all findings from root cause analyses with the goal of identifying and addressing systemwide vulnerabilities. Known as common cause analysis, this review identifies common, cross-departmental themes. Once identified, themes are prioritized based on frequency of occurrence and professional judgment. A safety team then works with senior hospital leaders and other relevant staff to implement changes to address the main themes and prevent future events. A process for tracking and addressing less serious events is also in place. Key elements of the common cause analysis program are described below:
- Root cause analysis of every serious safety event: Immediately after every serious safety event resulting in patient harm or a near miss, the patient safety officer charges a root cause analysis team to investigate the incident.
- Team composition: The team includes a clinical process manager, physician or nurse team leader with expertise relevant to the event, and five or six additional frontline staff and physicians chosen to make the team representative of the roles and practices involved in the event.
- Event analysis: The root cause analysis team holds three 2-hour meetings to analyze the event and review it from a systems perspective. Participants identify factors that contributed to the incident by reviewing each step leading up to it. Once vulnerabilities are identified, they are sorted by category and the team prepares a final report with recommended improvement actions. Urgent changes are implemented immediately.
- Executive sponsor to ensure corrective action: Information provided in November 2012 indicates that an executive sponsor at the vice president level now participates on each root cause analysis team. The executive sponsor has oversight responsibility and accountability for the team's work. He or she reviews the corrective action plan, ensures that sufficient resources are available for the corrective action, and confirms that the corrective action is taken at the local level.
- Root cause advisory team: Information provided in November 2012 indicates that a root cause advisory team—consisting of the hospital's chief operating officer, chief medical officer, chief nursing officer, legal team, and safety team—also reviews all cases and tracks progress in real time.
- Database tracking: Information provided in November 2012 indicates that all vulnerabilities and suggested improvements included in the final reports are documented in a database, which is used to track completion of improvement actions and to provide hospitalwide data for a subsequent common cause analysis review (described below).
- Monthly case review: The patient safety committee—which includes unit-level medical directors; leaders from nursing, pharmacy, information systems, and risk management; and other administrative leaders—reviews final root cause analysis reports at monthly meetings, confirming that action items are either appropriately handled locally or are within the scope of existing committees. For example, if it is determined that the hospital's formulary does not clearly specify dosing information related to a certain medication, the therapeutic standards committee is charged with implementing the changes.
- Annual common cause analysis of common themes and problems: Throughout the year, the patient safety committee maintains the database of action items, tracks completion, and mines the data for an analysis of common themes, called common cause analysis. Information provided in November 2012 indicates that, since 2010, the committee has been using a revised process for identifying and tracking vulnerabilities. The new process includes first determining if there was a deviation from generally accepted practice standards during patient care associated with an event; if so, each deviation is described both from the individual and system perspective. The committee members determine who did what and why, identify the particular process and activity under way when the inappropriate event occurred, and identify system failures. Using an established list of individual and system "failure modes," the committee members then analyze the events collectively to identify themes of care deviations that result in harm. As a result of this process, common themes and vulnerabilities begin to emerge, such as poor communication of information, insufficient training, excessive distractions, insufficient use of existing technology and equipment, and cultural expectations.
- Prioritizing themes: Information provided in November 2012 indicates that the committee members prioritize themes to address based on frequency of occurrence and professional judgment.
- Safety initiatives to correct vulnerabilities: The committee then develops plans to implement changes to address the most critical themes. For example, one early theme from the annual common cause analysis was characterized as follows: "Evaluate and implement a safe and effective nurse-call system. Include an evaluation of staffing requirements, downtime procedures, and standard operating practices for all users." To address this issue, the hospital made improvements to the cardiorespiratory monitoring systems and the associated nurse-call system, along with significant changes in practice, equipment, and associated systems across the institution. The hospital also changed staffing patterns and better defined responsibilities for responding to alarms. Another possible initiative would be to request budget funding for new equipment purchases to improve safety, such as intravenous pumps with fail-safe mechanisms to ensure accurate administration of intravenous medications.
- Process for analyzing less severe events: Information provided in November 2012 indicates that the hospital has also developed a process for evaluating less serious events that reached the patient but resulted in moderate, mild, or no harm (known as precursors) and near misses (events that did not reach the patient). This process, called apparent cause analysis, is a shorter process handled locally by frontline staff on the units. Unit staff members are trained by the patient safety committee to use templates to review all precursors and near misses to determine why these events occurred and what individual and system factors were involved. Unit staff complete a form detailing the event and send the form to the patient safety committee, which enters the information into the database, reviews the information, and provides feedback to the unit regarding correction of vulnerabilities.
References/Related ArticlesBrowne AM, Mullen R, Teets J, et al. Common cause analysis: focus on institutional change. In: Henriksen K, Battles JB, Keyes MA, et al., editors. Advances in patient safety: new directions and alternative approaches. Vol. 1. Rockville, MD: Agency for Healthcare Research and Quality, 2008. Available at: www.ncbi.nlm.nih.gov/books/NBK43639/pdf/advances-browne_5.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .).
Healthcare Performance Improvement. SECSM & SSERSM Patient Safety Measurement System for Healthcare. [HPI White Paper Series]. 2009. Available at: http://hpiresults.com/docs/PatientSafetyMeasurementSystem.pdf.
Contact the InnovatorAnne Marie Browne, MSN, RN
Senior Patient Safety Manager
The Center for Quality and Patient Safety
Children's Hospital of Philadelphia
34th Street and Civic Center Boulevard
Philadelphia, PA 19104
Innovator DisclosuresMs. Browne reported having no financial interests or business or professional affiliations relevant to the work described in this profile.
ResultsAlthough there has been no formal evaluation of the impact of common cause analysis on patient safety, patient mortality, or legal liability, anecdotal reports suggest that the process has allowed the hospital to identify and address important safety problems and has enhanced the quality of communication about safety issues with organizational leaders.
Suggestive: The evidence consists of post-implementation reports about the ability of common cause analysis to identify patient safety and outcome vulnerabilities and to spur organizational action and support in addressing these vulnerabilities.
- Enhanced ability to identify common themes: Patient safety leaders report that the root cause analysis reviews, while identifying vulnerabilities, cannot on their own identify priorities that cut across units and departments. In contrast, these leaders believe that common cause analysis findings help enhance the alignment of department-specific efforts with organizational priorities and that the process provides greater confidence that the hospital is working on the most critical issues affecting patient safety.
- Successful addressing of many vulnerabilities: Since program inception, many common themes have been identified, allowing vulnerabilities to be successfully addressed.
- Better communication and more credibility with leaders: Information provided in November 2012 indicates that common cause analysis has improved the effectiveness of communications about vulnerabilities with senior leaders. In particular, since 2010, consistency around the terminology used has facilitated more accurate communication. In addition, because they are based on a comprehensive, objective system, common cause analysis findings have had a powerful impact when presented to operational and physician leaders and the hospital's board of trustees. These leaders report that common cause analysis inspires confidence that the identified problems represent the most important vulnerabilities facing the institution.
- Contribution to reduction in serious safety event rate: Information provided in November 2012 indicates that since the implementation of the program, the organization's serious safety event rate has dramatically declined. Due to the institution's overall focus on improving safety, it is hard to attribute this decline solely to common cause analysis, but this initiative has been a meaningful contributor.
Context of the InnovationChildren's Hospital of Philadelphia is a 500-bed pediatric hospital that provides a range of inpatient medical, surgical, intensive care, emergency, and rehabilitative services. The hospital's implementation of the common cause analysis process grew out of an awareness that relying exclusively on root cause analysis findings for patient safety created the risk that larger themes might be overlooked. An external consultant suggested that common cause analysis be considered, which has been successfully applied in other high-risk industries, such as nuclear power, but not widely implemented in health care.
Planning and Development ProcessKey steps included the following:
- Standardizing and tracking root cause analysis: The hospital developed a consistent approach to root cause analysis and set up a comprehensive database to track all findings from it, including actions taken on identified problems. This database serves as the foundation for the annual common cause analysis used at the hospital.
- Conducting literature search: Program leaders conducted a literature search in an attempt to learn from the successes and challenges faced by others in health care related to common cause analysis. However, no literature surfaced to guide this effort.
- Training: Staff received training in failure modes and effects analysis that aided in assigning the risk priority number. (This number is no longer used.)
- Enhancing process: Information provided in November 2012 indicates that the process has been enhanced through work with a consultant, addition of executive sponsors to ensure that corrective action plans are implemented, and development of a database to track events and corrective actions.
Resources Used and Skills Needed
- Staffing: The common cause analysis process is overseen by a four-person team that includes the patient safety officer and three clinical process managers. Information provided in November 2012 indicates that the team has been expanded to include an additional manager and medication safety officer.
- Costs: Development and operational costs of the initiative cannot be shared. No financial outlay is required; the staff members listed above spend some portion of their time on common cause analysis.
Funding SourcesChildren's Hospital of Philadelphia
The common cause analysis process is covered by the hospital's internal operating budget.
Tools and Other ResourcesInformation on root cause analysis is available on the U.S. Department of Veterans Affairs National Center for Patient Safety Web site at: http://www.patientsafety.va.gov/vision.html#rca.
Getting Started with This Innovation
- Keep team relatively small: The patient safety team must work well together on the common cause analysis process. If the team gets too large, it may become difficult to remain focused on critical priorities and move quickly to develop and implement changes.
- Develop strong recordkeeping process: Common cause analysis will not work unless the root cause analysis process produces detailed, timely, and accurate information. To that end, findings from the root cause analysis process must get entered into the hospital database quickly and accurately.
- Consider themes when determining organizational priorities: For example, an isolated case may reveal a vulnerability with "human factors–communication." It may be attributed to human error or poor judgment by some. It is not until similar human factors–communication issues arise in multiple cases, and a theme is recognized, that the vulnerability should be considered a broad, systems issue worthy of being a high priority for the organization.
Sustaining This Innovation
- Communicate findings throughout facility: The patient safety team should provide regular updates on common cause analysis activities (such as the themes revealed by the annual review and progress on the implementation of changes) at staff meetings and through e-mail and other communications. Over time, the level of transparency regarding improvements and successes should increase so as to maintain credibility with staff. For example, information provided in November 2012 indicates that the hospital has expanded its education and datasharing efforts to include posting of safety stories on the hospital intranet. Furthermore, the hospital now holds monthly meetings to discuss patient safety events, during which the lessons from common cause analysis are shared broadly.
- Be open to all sources of vulnerabilities: The patient safety team should look for action items and vulnerabilities that go beyond those identified in root cause analysis.
Browne AM, Mullen R, Teets J, et al. Common cause analysis: focus on institutional change. In: Henriksen K, Battles JB, Keyes MA, et al., editors. Advances in patient safety: new directions and alternative approaches.
Vol. 1. Rockville, MD: Agency for Healthcare Research and Quality, 2008. Available at: http://www.ncbi.nlm.nih.gov/books/NBK43639/pdf/advances-browne_5.pdf
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Service Delivery Innovation Profile
Original publication: August 04, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: October 23, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: November 14, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.