RCA The problem with root cause analysis challenges
RCA 基礎班﹝二﹞ The problem with root cause analysis challenges facing the usage of RCA in healthcare Introduction => Box 1: Lessons not learnt 1. 2. 3. 4. 5. 6. 7. 8. 9. The unhealthy quest for ‘the’ root cause Questionable quality of RCA investigations Political hijack Pooly designed or implemented risk controls Poorly functioning feedback loops Disaggregated analysis focused on single organisations and incidents Confusion about blame The problem of many hands Discussion 如果我不做功课,给我做功课的要点是什么 http: //qualitysafety. bmj. com/content/qhc/early/2016/06/23/bmjqs-2016 -005511. full. pdf 3
RCA 基礎班﹝二﹞ Introduction 介紹 • Attempts to learn from high-risk industries such as aviation and nuclear power have been a prominent feature of the patient safety movement since the late 1990 s. One noteworthy practice adopted from such industries, endorsed by healthcare systems worldwide for the investigation of serious incidents, is root cause analysis (RCA). Broadly understood as a method of structured risk identification and management in the aftermath of adverse events, RCA is not a single technique. Rather, it describes a range of approaches and tools drawn from fields including human factors and safety science, that are used to establish how and why an incident occurred in an attempt to identify how it, and similar problems, might be prevented from happening again. In this article, we propose that RCA does have potential value in healthcare, but it has been widely applied without sufficient attention paid to what makes it work in its contexts of origin, and without adequate customisation for the specifics of healthcare. As a result, its potential has remained underrealised and the phenomenon of organisational forgetting remains widespread (box 1). Here, we identify eight challenges facing the usage of RCA in healthcare and offer some proposals on how to improve learning from incidents. • 從 1990年代晚期開始,嘗試從高風險產業如 航空業及核能業學習成為病患安全運動的顯 學。其中一項最為人知,被全世界醫療照護 系統引用,作為重大事件調查使用的方法就 是根本原因分析(Root Cause Analysis),簡 稱 RCA。RCA最廣為人知的,是一種在不良 事件發生後的結構性風險辨識及處理的方法, 但RCA並不只是一種技巧而已。RCA描述的是 一系列包括人因科學和安全科學領域中所淬 煉出來的方法及 具。用於了解事件是如何 及為何會發生,並嘗試去辨識出如何去預防 及讓這次或以後類似的問題不要再次發生。 在此篇文章中,我們提出RCA在醫療照顧產 業有其應用的潛力及價值,但是長久以來的 應用上,對於原文中真正的成功因素並沒有 受到足夠的關注,並且對於醫療照顧產業的 特性也沒有足夠的客製化。因此,RCA的潛 力仍然是沒有被完全了解的,而且“組織性的 遺忘“的狀況仍是非常普遍(Box 1)。在此, 我們提出了在醫療照顧上使用RCA的八項挑 戰,並對如何改善從事件中學習提出一些提 議。 http: //qualitysafety. bmj. com/content/qhc/early/2016/06/23/bmjqs-2016 -005511. full. pdf 4
RCA 基礎班﹝二﹞ Lessons not learnt [box 1] 沒有學到的教訓 • • • This example provides a summary of a real case that occurred in a hospital and the failure to learn from the incident in spite of a root cause analysis. In a large acute hospital, a patient underwent a routine cataract surgery—an operation with a minimal risk profile—led by an experienced ophthalmologist. The wrong lens was inserted during the operation. The error was promptly recognised postoperatively; the patient was returned to the operating room and the procedure was safely redone. A subsequent root cause analysis identified that two lenses were in the operating room, one (the wrong one) brought in by an operating department assistant and the other by the surgeon. The investigation report identified that having more than one lens in the operating room and a failure in the double-checking process had caused the incident. The action plan included the development of a new protocol emphasising the individual responsibility of the surgeon to select the appropriate lens, a training programme, improved documentation and a poster emphasising the importance of double checks. One year later, in the same hospital, a different patient with a different surgeon had the same procedure. Once again, the wrong lens was implanted. This time, the staff member who chose the wrong lens was the surgeon. • • • 本例提供了一個真實的案例,發生在医院和 儘管有使用根本原因分析手法,但未能從事 件中学習。 描述在一家大的急性外科醫院,一位病人接 受白內障手術,應是風險最小的手術,由一 位有經驗的眼科醫師執行,在操作過程中插 入錯誤的鏡頭,於術後及時發現錯誤,立即 將病人即時送回手術室,依照安全程序重做 一次。 後續根本分析,確認那两個镜頭在手術室, 錯誤的那一個鏡頭由操作部門助理带來,另 一個由外科醫師帶入;調查報告確定在手術 室內有多個鏡片,且因雙重檢查過程失敗導 致發生此事件。 行動計劃包括制定新協議,強調外科醫生個 人責任應該選擇合適的鏡片,改進培訓計劃 文件和張貼海報強調雙重檢查的重要性. 一年後,在同一家医院,不同外科医生的患 者接受相同的術式。再一次植入錯誤的鏡片, 這次選擇錯誤鏡頭的 作人员是外科醫師。 http: //qualitysafety. bmj. com/content/qhc/early/2016/06/23/bmjqs-2016 -005511. full. pdf 5
RCA 基礎班﹝二﹞ The unhealthy quest for ‘the’ root cause 不合理的追求獨一無二的『根本原因』 • The first problem with RCA is its name. By implying—even inadvertently—that a single root cause (or a small number of causes) can be found, the term ‘root cause analysis’ promotes a flawed reductionist view. Incident investigation in the aftermath of an adverse event is intended to identify the latent and active factors contributing to the genesis of a particular adverse event, but too often results in a simple linear narrative that displaces more complex, and potentially fruitful, accounts of multiple and interacting contributions to how events really unfold. This is a tendency exacerbated by use of some RCA techniques (such as timelines or the ‘five whys’) that tend to favour a temporal narrative rather than a wider systems view. • RCA的問題源自它的名字。即 使無意間可以找到單一的根本 原因(或少量原因),「根本原 因分析」一詞也促成了還原真 相的錯誤。不良事件後的調查 目的在於發現導致不良事件發 生的潛在和現有因素,但往往 導向一種簡單的線性敘述,這 種簡單的線性敘述取代了更複 雜和潛在的多重和相互作用的 問題,事件該如何真正呈現。 當使用一些時間敘述的RCA 具(如:時間序列表或「五個 為什麼」),而不是廣泛性透 過系統觀點的RCA技術時,反 而易造成問題惡化的傾向性。 http: //qualitysafety. bmj. com/content/qhc/early/2016/06/23/bmjqs-2016 -005511. full. pdf 6
RCA 基礎班﹝二﹞ Questionable quality of RCA investigations RCA調查品質的問題 • Once an adverse event is classified as meeting the definition of a serious incident, an RCA is supposed to involve the convening of a skilled multidisciplinary investigation team, preferably with representations from risk management personnel and clinical teams. Over a predefined timeframe, which is mandated in some countries (60 days in the UK, 45 days in the USA), this team collects and analyses data and formulates an action plan. However, challenges pertaining to the quality of this process abound. The task facing the investigation team is far from straightforward: the events underlying an incident have to be reconstructed from many different sources of varying degrees of reliability, usefulness and accessibility, ranging from hospital records, staff interviews and statements, to records of workforce rotas. The information obtained directly from healthcare workers is influenced by their willingness and ability to provide relevant data, and by nature of the relationships and conversations between investigators and other stakeholders. The involvement of patients and families affected by the incident is wildly variable, with only limited evidence-based guidance on how it can best be done. Yet, despite the complexities, sensitivities and challenges of this work, RCAs in healthcare typically conducted by local teams, not the expert accident investigators who are proficient in systems thinking and human factors, cognitive interviewing, staff engagement and data analysis that are characteristic of other highrisk industries. Further, inconsistent use is made of the various investigative tools that are available. As a result, exemplary practice in the analysis of healthcare incidents is rare. • 當不良事件被定義為嚴重的事件時,應該召 開一個熟練多領域的RCA調查團隊,最好成 員是來自風險的管理人員和臨床團隊的代表。 如某些國家訂好一個時間完成此任務(在英國 45 天及在美國 60 天),成立小組來收集、分 析資料及制定行動計劃。然而,調查小組的 任務並不簡單︰事件發生後需推敲不同程度 的可靠性來源、有用處的資料、常規的記錄、 作人員的訪談和陳述,到員 排班表記錄。 而來自醫護人員資訊因受到他們提供資源的 意願和能力的影響,以及調查員和其他利益 攸關者之間的關係及訪談的性質。另請受到 此事件患者和家庭參與是會出現很大變數, 如果要這麼做須在有證據醫學佐證下才行。 然而,儘管複雜、敏感和這項 作的挑戰性, 醫療領域的RCA在醫療保健通常由單位團隊 進行,而不是由精通系統思考和人為因素、 認知面試、 作人員參與和資料分析等之專 家事故調查人員負責。此外,尚存在不一致 的使用各種調查 具,因此,模範實踐中的 醫療事件分析是罕見的。 http: //qualitysafety. bmj. com/content/qhc/early/2016/06/23/bmjqs-2016 -005511. full. pdf 7
RCA 基礎班﹝二﹞ Political hijack 政策劫持 • Constrained by strict timelines, and skewed by hindsight bias and lack of independence from the organisation where the event took place, RCAs in healthcare often end up a compromise between ‘depth of data and accuracy of the investigation’. The quest to complete an investigation on time and produce a report risks goal displacement, where the report is seen as the end product rather than the beginning of a learning cycle. Reports themselves, influenced by the need to preserve interpersonal relationships and by hierarchical tensions and partisan interests, may not always reflect the content of discussions during investigations nor the realities of what happened. Investigating teams may end their analysis once they have reached a cause of mutual convenience, perhaps one that edits out causes (and thus solutions) deemed to be beyond the remit or capacities of the organisation and that occludes deeper organisational and sociopolitical dynamics. • 這個段落有四個重點:第一個,因為 受限於時間窘迫以及事後偏誤扭曲, 當事件發生時組織內又缺少獨立的調 查,以致醫療機構的RCA常妥協於” 深入蒐集資料和調查準確性”之間。 第二個,要求準時完成RCA調查和產 出報告會發生目標被替代的風險,而 且報告只看重是否完成而忽略這應該 是學習循環的開始。第三個是報告本 身,(因為不是獨立調查)會到受到保 持現有人際關係和階級關係緊張和派 系利益影響,可能沒有反應調查時討 論的內容也沒有真實反應事實的真相。 第四個,調查小組可能結束分析當小 組找到一個相互便利(可以交差)的原 因,或許調查小組編輯原因(而且加 上解決方案)但被視為超過職權範圍 或是組織能力之外,而這個結果掩蓋 了更深層次的組織及社會政治動態。 http: //qualitysafety. bmj. com/content/qhc/early/2016/06/23/bmjqs-2016 -005511. full. pdf 8
RCA 基礎班﹝二﹞ Poorly designed or implemented risk controls 設計不當或實施風險控制 • The key goal of RCA is to prevent similar events from recurring. But few studies have investigated the nature and effectiveness of risk control strategies stemming from RCA investigations in healthcare. The available evidence points to the endemic tendency of investigators to settle for administrative and perhaps ‘weaker’ solutions (such as reminders) rather than those that address the latent causes, such as poorly designed technology or defective operational systems. Again, some of the reasons for this lie in the limited expertise of local investigation teams in selecting and designing appropriate risk controls. Only limited guidance is available and what is available may not be sufficiently attentive to the specifics of the healthcare context. Yet poorly designed or ineffectual corrective actions may do harm. Among other unintended consequences, risk migration, where attempts to mitigate a risk create new risks, may easily occur. Recommended actions may also, of course, result in little change, especially (but not only) when senior managers are not involved in the generation of action plans and do not support their implementation. Despite the time and effort invested in RCAs, few incentives exist to follow-up formally on action plans: estimates of implementation rates vary between 45% and 70%. • • • RCA的關鍵目標是防止類似的事件重複發生。 但是很少有研究調查了RCA在醫療保健調查中 產生的風險控制策略性質和有效性。 現有證據表明調查人員解決行政或“較弱”的 解決方案(例如提醒)的趨勢,而不是解決潛 在原因,例如設計不善或有缺陷的操作系統。 然而,其中一些原因是因為調查小組在選擇和 設計適當的風險控制方面的專業知識有限。只 有有限的指導可用或者其指導可能不夠注意醫 療背景的細節。設計不良或無效的糾正措施可 能會造成傷害。除了其他意想不到的後果之外, 風險轉移可能會很容易發生。如果嘗試減輕風 險可能很容易發生新的風險。 當然,建議的行動也有可能,當然,也不會產 生任何變化,特別是(而不僅僅是)當高階管 理人員不參與制定而且也不支持執行行動計劃。 儘管RCA投入了大量時間和精力,但在行動計 劃上正式採取的措施仍然很少:實施率估計在 45%至 70%之間。 http: //qualitysafety. bmj. com/content/qhc/early/2016/06/23/bmjqs-2016 -005511. full. pdf 9
RCA 基礎班﹝二﹞ Poorly functioning feedback loops 反饋循環不良 • For learning to occur, several conditions must be satisfied. Among the most important of these are the sharing of the outcomes of incident analysis with those involved, those who reported, and those likely to be affected in the future, especially in implementing recommendations. Evidence in other fields suggests that learning from events does not happen by itself: purposeful intent is needed both to disseminate the findings and ensure that the recommended actions made salient and actionable. Yet, as currently practised, feedback mechanisms in healthcare RCAs function poorly, contributing to the disenchantment of staff and frustrating the kind of double-loop learning needed to secure change. • 為了學習,有一些條件必須 被滿足。其中最重要的是, 分享事件分析結果給相關人 員、通報者、和未來可能被 影響的人,特別是執行的建 議。在其他領域的證據顯示, 學習並不會從事件本身發生: 而是需要有意圖的傳播結果 並且確保所建議的行動方案 是顯著的和可行的。然而, 目前在醫療RCA的實踐反饋 機制功能並不好,導致 作 人員的失望與沮喪,這種雙 循環學習需要確保有改變。 http: //qualitysafety. bmj. com/content/qhc/early/2016/06/23/bmjqs-2016 -005511. full. pdf 10
RCA 基礎班﹝二﹞ Disaggregated analysis focused on single organisations and incidents 分析著重於單一組織和事件 • The current RCA approach favours analysis of individual incidents in isolation and within bounded organisations. The consequent tendency to generate localised action plans that are not shared more widely may result in failure to disseminate painfully acquired learning and to address deeper, institutionally engrained patient safety concerns. Single incident analysis also frustrates the organisation's ability to assess its vulnerability to recurring events. Organisations' inability to effectively prioritise actions may lead to an unwarranted commitment of resources to averting specific very rare events rather than addressing the conditions that allowed the event to occur. Though mechanisms for aggregating learning from incidents and creating alerts do exist in some countries, their impact to date has been limited: similar events often recur in the same or similar organisations (box 1), suggesting failure to learn both within and across organisations. • 目前的RCA方法偏袒於限制於組織 內的個別事件的分析。因此產生 局限性的行動計畫,無法更廣泛 的分享導致無法傳播這些痛苦經 驗的學習,並且去解決更深層次 的,制度化的患者安全問題。單 一事件分析也使組織的能力無法 去有效評估對反覆出現事件的弱 點。組織無法有效地確定行動優 先次序可能導致資源無效的投入, 去避免具體的極少數事件,而不 是解決允許事件發生的條件。雖 然有些國家存在著從事件學習匯 總和制定警報的機制,但他們迄 今為止的影響是有限的:類似的 事件往往在相同或類似的組織中 重複發生(BOX 1),這表明在組 織內部和組織之間無法學習。 http: //qualitysafety. bmj. com/content/qhc/early/2016/06/23/bmjqs-2016 -005511. full. pdf 11
RCA 基礎班﹝二﹞ Confusion about blame 關於“咎責”的錯亂 • Though healthcare is often exhorted to embrace a ‘no-blame’ culture, the extent to which this urging is based on a correct understanding of what happens in other high-risk industries is questionable. Investigators in other industries do not set out with a remit to assign blame, but that does not mean that individual or organisational culpability is forever sequestered. The vast majority of mistakes and other errors are the result of systems defects that need to be corrected, but when blatant transgressions, neglect or unacceptable behaviour is found, it is clearly wrong to write accountability out of the picture. Nor is no-blame the reality in practice, since disciplinary, institutional and legal (civil and criminal) processes continue to operate and are highly visible to healthcare practitioners and managers, yet may appear arbitrary and unsatisfactory both to them and to patients and families. A ‘just culture’ is increasingly promoted in many organisations to balance the disparity between individual blame and organisational accountability. This approach, however, comes with problems of its own when applied to incident investigation in healthcare. For instance, some of the more visible features of the just culture philosophy in incident investigation is the use of prescriptive algorithms and decision tools (such as culpability tree) to objectify culpability. Such ‘calculus-like logic’ may imply that actions committed by staff are binary (either acceptable or unacceptable) without appropriate appreciation of the messiness of the system in which the action occurred. • • 在醫療照護中經常鼓勵信奉所謂「不咎責(no-blame) 」文化。這樣的主張是基於對其他高風險產業中所發生 事件的正確認知,但要到什麼程度是不確定的。 其他產業中調查人員一開始不會預設立場要歸咎責任, 但並非意味個人或機構的咎責會永遠被免除。雖然絕大 多數的錯誤都是由於需要被改正的系統性缺陷所造成, 但是當公然違法、過失或不當行為發生時,不去追究責 任顯然是錯的。在實務上「不究責」也是不切實際的。 因為當機構內懲戒以及法律上(民事及刑事)的程序持 續在進行,同時也受到醫療機構人員及主管高度關注時, 「不究責」的態度對於他們以及病人和家屬都是獨斷且 不令人滿意的。現在有愈來愈多的機構在推行所謂的「 公正文化(just culture)」,以期在個人咎責和機構責 任間取得平衡。但是這樣的做法適用於醫療照護的事件 調查時仍然會產生問題。舉例來說,以公正文化的概念 在進行事件調查時,常會使用規定流程(prescriptive algorithm)及決策 具(例如:責任樹(culpability tree))來決定責任歸屬。然而在沒有針對行為發生時 系統的混亂給予適當評價前,這種「類演算邏輯」可能 隱含當事人的行為是雙向不確定性(既可以是可接受的, 也可以是不可接受的)。 http: //qualitysafety. bmj. com/content/qhc/early/2016/06/23/bmjqs-2016 -005511. full. pdf 12
RCA 基礎班﹝二﹞ The problem of many hands 太多的廚師破壞了肉湯 • RCA is further challenged by the problem of many hands, which describes the problem that many actors and their actions may contribute to an outcome, yet no individual is responsible either for that outcome or fixing the problems that caused it. This problem, which is endemic in healthcare, makes it difficult to address hazards that arise at the level of the system, since many of the actors that are implicated in hazards—including, for example, drug and equipment suppliers—are outside the direct control of individual care organisations. RCA investigations may fail to assign responsibility to such actors, instead reabsorbing responsibility into the organisation where the incident occurred. These organisations typically lack the legal mandate, resources and structural authority necessary to make the changes required. • RCA有許多挑戰來自許多單位 (hands) • 如和問題相關的很多人員, 他們 的行為產生結果, 但這些結果卻 無單位可以協助解決。 • 這問題在醫療機構相當普遍, 在系統層面產生危害困難解決 • 因涉及危害的行為者非在醫院 組織內,如藥商和設備廠商。 • RCA調查無法追究行為者的責 任 • 這些外包廠商缺乏法律及權利 責任。 http: //qualitysafety. bmj. com/content/qhc/early/2016/06/23/bmjqs-2016 -005511. full. pdf 13
RCA 基礎班﹝二﹞ Discussion (1) 討論 • RCA is a promising approach with considerable face validity as a way of producing learning from things that have gone wrong. But it has consistently failed to deliver benefits on the scale or quality needed. The eight problems we have discussed here mean that, too often, RCA results in the tombstone effect: though its purpose is to guard against a similar incident in the future, it may instead function primarily as a procedural ritual, leaving behind a memorial that does little more than allow a claim that something has been done. Incident investigation clearly will continue to play an important role in making healthcare safer, but it must first get better at doing what it does. • RCA是一個有前途的方法藉大 量面對正確性(標靶)當作一種 學習,從已經做錯事情產生。 但是無法在效益規模或品質需 要上傳達。那是因為本文討論 的八個問題造成”樣板(墓碑)效 應”(套用一樣的格式):RCA目 的被認為是避免類似事件未來 再發生,功能被替代而成為一 個程序儀式,僅留存做了一點 點的記憶卻允許聲稱已經做了 一些事情。在健康照護更安全, 事件調查清楚將繼續扮演重要 的角色,第一步是要做到「到 位」。 http: //qualitysafety. bmj. com/content/qhc/early/2016/06/23/bmjqs-2016 -005511. full. pdf 14
RCA 基礎班﹝二﹞ Discussion (2) 討論 • The first step in securing improvement is likely to involve the • professionalisation of incident investigation: those conducting it need specialist expertise in underlying theories, ergonomics, human factors and hands-on experience of analytical methods. For these reasons, the establishment of professional investigatory bodies, such as the one shortly • to be launched in the UK, are welcome—though the scope, reach and impact of such bodies will need careful monitoring. Second, the role of patients and relatives in the investigative process needs to be recognised and valued. Such engagement has the potential to generate a unique • perspective of the service provided from the end-user's perspective and may foster dialogue that is informative to both causal analysis and design of risk controls. The psychological and emotional readiness of patients and families involved in the investigative process needs to be considered, along with the maturity and ability of the organisation to facilitate such a process within the appropriate legal framework. Transparency on the agreed level of involvement is paramount from the start and the outcomes of investigations should be available to patients and relatives, though clarity • on how this should best be done is not yet available. Third, better understanding of the role of blame is needed. The dissonance caused by claims of no-blame or even just culture and the reality is a source of confusion and distress in relation to RCAs. To address current confusions, clarity is needed on the distribution of responsibility between bodies investigating incidents (whose prime mandate would be to promote learning) and other bodies (including professional regulators and the law courts), and in what instances the investigative body needs to make referrals. 確保改進的第一步可能涉及事件調查的專業 化:執行此類 作的專業人員需要`具有專業 知識的基礎理論,如人體 程學、人為因素 和分析方法的實踐經驗。 由於這些原因,應建立專業調查機構,例如 在英國將發起專業調查機構,儘管這些機構 的範圍、影響程度需要仔細被監測。 第二,患者和親屬在調查過程中的作用需要 得到承認和重視。這種參與有可能從最終用 戶的角度引導事件的演變,並可能促進對因 果分析和風險的控制時,需要考慮參與調查 過程的患者和家屬的心理和情緒準備情況, 以及組織在法律框架內促進此類過程的成熟 度和能力。 第三,需要更好的了解責任。因為無責任甚 至是文化所引起的不和諧,是為現實RCA的 混亂和困擾的根源,為了解決目前的困惑, 需要明確調查事件(其主要任務是促進學習) 的機構與其他機構(包括專業監管機構和法 院)之間的責任分配,以及調查機構需要做 哪些事情轉介。 http: //qualitysafety. bmj. com/content/qhc/early/2016/06/23/bmjqs-2016 -005511. full. pdf 15
RCA 基礎班﹝二﹞ Discussion (3) 討論 • • Fourth, healthcare must focus increasingly on aggregated analysis of incidents. Such a bird's eye view of incidents may facilitate prioritisation • of interventions, based on the harm associated with incidents and also on the associated risks. Aggregated analyses can be performed at numerous • levels of the organisational hierarchy, for example, the micro (within one department) and at the meso level (organisational). At the national level, • aggregated analyses offer a way of identifying common themes across similar and apparently more disparate incidents and may also serve as a means of generating actions that require collaborative efforts between healthcare organisations or indeed between industry and healthcare. Such • an example could be for instance product redesigning—a solution that may not be identified through the analysis of a single incident within one department but may reveal itself as a recurring theme when analysing multiple incidents across many organisations. Linked to this, healthcare • urgently needs to develop and evaluate much better methods for designing risk controls and other improvement actions. One possibility that could be evaluated, for example, is that of a hierarchy of risk controls. More broadly, the use of active surveillance of issues that have already been detected and monitoring of effectiveness of risk controls need to become a routine part of the risk management process following RCAs. Healthcare • also needs to markedly improve its capacity to evaluate, curate and share these risk controls. Such an approach would help to address the problem that organisations tend to constantly reinvent risk controls, resulting in waste and the creation of new risks. An easily accessible database with • descriptions of risk controls and contexts would enable lessons learnt from one RCA to be shared widely and support a participatory approach to organisational learning. 第四,醫療保健必須越來越重視對事件的綜合分析。 這種鳥瞰事件可能有助於根據與事件相關的傷害以 及相關風險來確定乾預措施的優先級。 可以在組織層次結構的許多層次上進行聚合分析, 例如,微觀(一個部門)和中層(組織)。 在國家層面上,綜合分析提供了一種在類似和明顯 更加不同的事件中確定共同主題的方法,也可以作 為需要採取行動的手段,需要醫療機構之間或者在 行業與醫療保健之間進行合作。 這樣的一個例子可能是產品重新設計 - 一個解決方 案,可能無法通過分析一個部門內的單個事件來識 別,但在多個組織中分析多個事件時可能會將其本 身視為一個反復出現的主題。 與此相關聯,醫療保健迫切需要開發和評估更好的 方法來設計風險控制和其他改進措施。例如,可以 評估的一種可能性是風險控制層級。更廣泛地說, 使用對已經被檢測到的問題進行主動監視並監測風 險控制的有效性需要成為RCA之後的風險管理流程 的常規部分。 醫療保健也需要顯著提高其評估,策劃和分享這些 風險控制的能力。這種方法將有助於解決組織傾向 於不斷重新開展風險控制,導致浪費和創造新風險 的問題。 一個易於訪問的有風險控制和背景描述的數據庫將 使得一個區域協調機構的經驗教訓得到廣泛分享, 並支持組織學習的參與式方法。 http: //qualitysafety. bmj. com/content/qhc/early/2016/06/23/bmjqs-2016 -005511. full. pdf 16
RCA 基礎班﹝二﹞ Discussion (4) 討論 • Finally, healthcare needs to do more to detect hazards and assess • risks proactively. RCA is essentially retrospective, and depends crucially on an incident being recognised as such, but that may not happen for a variety of reasons: healthcare personnel may have become habituated to particular practices or outcomes, or fear and other negative emotions discourage reporting. Though RCAs were imported from other high-risk industries, the other tools and techniques commonly used in those industries to assess systems and assure their safety before an incident has occurred—such as failure modes and effects analysis (FMEA), hierarchical task analysis and so on—have had far less attention in healthcare 66 FMEA, in particular, may be especially useful for the rigorous proactive risk assessment of a select few but high-priority hazards. 67 For healthcare truly to become a learning system, action is needed on multiple levels. RCAs have dominated for too long as the principal means of generating learning. The time has come to recognise both their opportunities and their limits 最終,醫療照顧者需要正積極主動地 去評估危害和風險。RCA本質上是追 溯性的,並且在很大程度上取决於被 認定的事件本身,但可能不會形成, 可能的原因有醫療人員習慣性地去做 某些特定行為或是害怕有一些負面的 情緒,這些原因都會造成他們不願意 去報告意外發生。雖然RCA是從別的 高危險的產業引進的,還有其他方法 或是 具在意外發生之前被拿來檢測 整個體系的安全性,像是FMEA或是 hierarchical task analysis等等,但這兩 種非法比起RCA還要更少應用在醫療 體系。FMEA對於精確並積極主動地 去評估一些少數但必須積極優先處理 的危害特別有效果。為了讓醫療真正 成為一個學習的系統,需要多層面的 行動。RCA已經是循環學習的主流太 久了,需要去了解RCA的機會與限制 在哪裡。 http: //qualitysafety. bmj. com/content/qhc/early/2016/06/23/bmjqs-2016 -005511. full. pdf 17
RCA 基礎班﹝二﹞ Discussion (5) 討論 • • • RCA是一個有前途的事 件調查技術從高風險的 業界引入,但是在醫 療照護產業沒有承襲並 發揮它的潛力 RCA is a promising incident investigation technique borrowed from other high-risk industries, but has failed to live up to its potential in healthcare. A key problem with RCA is its name, which implies a singular, linear cause. Other problems include the questionable quality of many RCAs, their susceptibility to political hijack, their tendency to produce poor risk controls, poorly functioning feedback loops, failure to aggregate learning across incidents and confusion about blame and responsibility. Implementation and evaluation of risk controls to eliminate or minimise identified hazards need to become a more visible feature of the RCA process. To maximise learning, lessons learnt from incidents, descriptions of implemented risk controls and their effectiveness need to be shared within and across organisations. http: //qualitysafety. bmj. com/content/qhc/early/2016/06/23/bmjqs-2016 -005511. full. pdf 18
RCA 基礎班﹝一﹞ 基礎班﹝二﹞ 目擊證人訪談 https: //qi. cch. org. tw/zh-tw/aq/rcaques/questions-to-ask-during-an-RCA-investigation 21
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