Our First Review in 12 Years: An Evaluation of Effectiveness of Root Cause Analysis in Hong Kong Public Hospitals

Abstract

Background: To evaluate the effectiveness of root cause analysis (RCA) and propose possible ways to enhance its effectiveness in Hong Kong public hospitals.Methods: A retrospective cross-sectional study was performed across 43 public hospitals and institutes in Hong Kong, reviewing RCA reports of all Sentinel Events and Serious Untoward Events within a two-year period. The incident nature, types of root causes and strengths of recommendations were analysed. The RCA recommendations were categorised as 'strong', 'medium' or 'weak' strengths utilizing the US's Veteran Affairs National Center for Patient Safety action hierarchy.Results: A total of 214 reports from October 2016 to September 2018 were reviewed. These reports generated 504 root causes, averaging 2.4 per RCA report, and comprising 282 (49%) system, 233 (46%) staff behavioural and 22 (4%) patient factors. There were 658 recommendations identified in the RCA reports with an average of 3.1 per RCA. Of these, 18 (2%) recommendations were rated strong, 116 (15%) medium and 626 (82%) weak. Most recommendations were related to 'training and education' (466, 61%), 'additional study/review' (104, 14%) and 'review/enhancement of policy/guideline' (39, 5%). Conclusions: This study provided insights about the effectiveness of RCA across all public hospitals inHong Kong. The results showed a high proportion of root causes were attributed to staff behavioural factors and most of the recommendations were weak. The reasons include the lack of training, tools and expertise, appropriateness of panel composition, and complicated processes in carrying out large scale improvements. The Review Team suggested conducting regular RCA training, adopting easy-touse tools, enhancing panel composition with human factors expertise, promoting an organization-wide safety culture to staff and aggregating analysis of incidents as possible improvement actions. Strengths And Limitations Of This StudyThis study is the first study evaluating the effectiveness of RCA in Hong Kong public hospitals.This study used a robust methodology to analyse the root causes and recommendations of RCA reports.This study highlighted the key factors contributing to the distribution of strengths of recommendations.The study only reviewed the strengths of recommendations but not the work progresses and feasibilities.