Health care registries used to track adverse events can provide an important service for the health care practitioner. Registry data can reveal causes and trends that can be used to educate others, particularly for rare events that are otherwise difficult to track. Dr. Imelda Tjia, Department of Pediatric Anesthesiology, Texas Children’s Hospital, Houston, Texas, and coauthors describe the initiation of a quality improvement project in 2006 by the Quality and Safety Committee of the Society for Pediatric Anesthesia, which was later developed by the Society for Pediatric Anesthesia into the quality improvement initiative known as Wake Up Safe (WUS) in 2008. Their review is published in this month’s issue of Anesthesia & Analgesia in the article titled “Wake Up Safe and Root Cause Analysis: Quality Improvement in Pediatric Anesthesia.”
The Wake Up Safe registry captures adverse events that happen during anesthesia or within 24 hours of receiving anesthesia that result in death, are life threatening, or result in prolonged hospitalization or disability. The registry also captures “never-events,” i.e., events or medical errors that should never occur. Currently, 22 institutions are part of the WUS initiative.
For each event submitted to the WUS registry, a committee of at least 3 anesthesiologists not involved in the event conducts an internal root-cause analysis. The committee also develops actions for improvement. The root cause analysis attempts to identify system changes that can reduce future risk. Part of the analysis is to determine if an error occurred, such as a failure of a planned action to be completed as intended, or the use of the wrong plan to achieve a purpose.
There are 3 important questions to be answered: What happened? Why did it happen? What can be done to prevent the event from happening in the future? A fourth question should be included after follow-up and the implementation of solutions: Has the risk of recurrence been reduced? Findings are then submitted to WUS. One goal of WUS is to standardize, though education of WUS members, the root cause analysis method used by most member institutions.
This is a clear, concise, and well-written review of the topic. Cases are included to illustrate the various root cause analysis techniques. In the next 2 posts, a case discussion and root cause analysis will be summarized so the reader can better understand how root cause analysis can be applied to a specific event.