Cargando…

What are the experiences of team members involved in root cause analysis? A qualitative study

BACKGROUND: Conducting root cause analysis (RCA) is complex and challenging. The aim of this study was to better understand the experiences of RCA team members and how they value their involvement in the RCA to inform future recruitment, conduct and implementation of RCA findings into clinical pract...

Descripción completa

Detalles Bibliográficos
Autores principales: Willis, Ruth, Jones, Tracie, Hoiles, Jo, Hibbert, Peter D., Schultz, Timothy J.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BioMed Central 2023
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10601107/
https://www.ncbi.nlm.nih.gov/pubmed/37880664
http://dx.doi.org/10.1186/s12913-023-10164-9
_version_ 1785126126211825664
author Willis, Ruth
Jones, Tracie
Hoiles, Jo
Hibbert, Peter D.
Schultz, Timothy J.
author_facet Willis, Ruth
Jones, Tracie
Hoiles, Jo
Hibbert, Peter D.
Schultz, Timothy J.
author_sort Willis, Ruth
collection PubMed
description BACKGROUND: Conducting root cause analysis (RCA) is complex and challenging. The aim of this study was to better understand the experiences of RCA team members and how they value their involvement in the RCA to inform future recruitment, conduct and implementation of RCA findings into clinical practice. METHODS: The study was set in a health network in Adelaide, South Australia. A qualitative exploratory descriptive approach was undertaken to provide an in-depth understanding of team member’s experience in participating in an RCA. Eight of 27 RCA team members who conducted RCAs in the preceding 3-year period were included in one of three semi-structured focus groups. Thematic analysis was used to synthesise the transcribed data into themes. RESULTS: We derived four major themes: Experiences and perceptions of the RCA team, Limitations of RCA recommendations, Facilitators and barriers to conducting an RCA, and Supporting colleagues involved in the adverse event. Participants’ mixed experience of RCAs ranged from enjoyment and the perception of worth and value to concerns about workload and lack of impact. Legislative privilege protecting RCAs from disclosure was both a facilitator and a barrier. Concern and a desire to better support their colleagues was widely reported. CONCLUSIONS: Clinicians perceived value in reviewing significant adverse events. Improvements can be made in sharing learnings to make effective improvements in health care. We have proposed a process to better support interviewees and strengthen post interview follow up. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12913-023-10164-9.
format Online
Article
Text
id pubmed-10601107
institution National Center for Biotechnology Information
language English
publishDate 2023
publisher BioMed Central
record_format MEDLINE/PubMed
spelling pubmed-106011072023-10-27 What are the experiences of team members involved in root cause analysis? A qualitative study Willis, Ruth Jones, Tracie Hoiles, Jo Hibbert, Peter D. Schultz, Timothy J. BMC Health Serv Res Research BACKGROUND: Conducting root cause analysis (RCA) is complex and challenging. The aim of this study was to better understand the experiences of RCA team members and how they value their involvement in the RCA to inform future recruitment, conduct and implementation of RCA findings into clinical practice. METHODS: The study was set in a health network in Adelaide, South Australia. A qualitative exploratory descriptive approach was undertaken to provide an in-depth understanding of team member’s experience in participating in an RCA. Eight of 27 RCA team members who conducted RCAs in the preceding 3-year period were included in one of three semi-structured focus groups. Thematic analysis was used to synthesise the transcribed data into themes. RESULTS: We derived four major themes: Experiences and perceptions of the RCA team, Limitations of RCA recommendations, Facilitators and barriers to conducting an RCA, and Supporting colleagues involved in the adverse event. Participants’ mixed experience of RCAs ranged from enjoyment and the perception of worth and value to concerns about workload and lack of impact. Legislative privilege protecting RCAs from disclosure was both a facilitator and a barrier. Concern and a desire to better support their colleagues was widely reported. CONCLUSIONS: Clinicians perceived value in reviewing significant adverse events. Improvements can be made in sharing learnings to make effective improvements in health care. We have proposed a process to better support interviewees and strengthen post interview follow up. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12913-023-10164-9. BioMed Central 2023-10-25 /pmc/articles/PMC10601107/ /pubmed/37880664 http://dx.doi.org/10.1186/s12913-023-10164-9 Text en © The Author(s) 2023 https://creativecommons.org/licenses/by/4.0/Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ (https://creativecommons.org/licenses/by/4.0/) . The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/ (https://creativecommons.org/publicdomain/zero/1.0/) ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
spellingShingle Research
Willis, Ruth
Jones, Tracie
Hoiles, Jo
Hibbert, Peter D.
Schultz, Timothy J.
What are the experiences of team members involved in root cause analysis? A qualitative study
title What are the experiences of team members involved in root cause analysis? A qualitative study
title_full What are the experiences of team members involved in root cause analysis? A qualitative study
title_fullStr What are the experiences of team members involved in root cause analysis? A qualitative study
title_full_unstemmed What are the experiences of team members involved in root cause analysis? A qualitative study
title_short What are the experiences of team members involved in root cause analysis? A qualitative study
title_sort what are the experiences of team members involved in root cause analysis? a qualitative study
topic Research
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10601107/
https://www.ncbi.nlm.nih.gov/pubmed/37880664
http://dx.doi.org/10.1186/s12913-023-10164-9
work_keys_str_mv AT willisruth whataretheexperiencesofteammembersinvolvedinrootcauseanalysisaqualitativestudy
AT jonestracie whataretheexperiencesofteammembersinvolvedinrootcauseanalysisaqualitativestudy
AT hoilesjo whataretheexperiencesofteammembersinvolvedinrootcauseanalysisaqualitativestudy
AT hibbertpeterd whataretheexperiencesofteammembersinvolvedinrootcauseanalysisaqualitativestudy
AT schultztimothyj whataretheexperiencesofteammembersinvolvedinrootcauseanalysisaqualitativestudy