awareness we can teach and learn from? The goal with root-cause
analysis is to keep asking why until you can't go any further.
In health care, answers tend to be multi-factorial. A lot of things
may contribute to a given problem, but if you don't investigate thor-
oughly, and really get to the bottom of why something happened —
and take corrective action — you won't fix the problem. You may
acquire some sense of how or why things went awry, but if you don't
get to the root cause, quite possibly, maybe even probably, the error
will happen again.
Zero isn't realistic
We've all heard the staggering numbers. Hundreds of thousands of
often-fatal medical errors happen every year. We're constantly exhort-
ed to think in terms of "never events" and to reduce the number to
zero. To me, that's misguided. As long as humans are involved in any
process, there are going to be errors. Instead, our focus should be on
zero avoidable errors. That goal, I believe, is attainable if we imple-
ment better reporting systems and better means of following up.
Unfortunately, the root cause is often missed in health care, where
reporting tends to be poor, analysis tends to be late and errors occur
so frequently that by the time we start to think about the root cause of
one, we're forced to deal with another. Many are avoidable, but we
don't get the chance to figure out how because we're too busy dealing
with the next incident, and then the next.
Practitioners often say, "You don't understand, our industry is dif-
ferent, patients are more complex," and so forth. It's true. You're
functioning in a very complex environment. But if you're determined
to really systematically address mistakes, get to the bottom of what
caused them, and try to put corrective actions in place, you can make
a difference. The alternative is that somebody puts a superficial or
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