Limitations

Dynamic, complex and highly interdependent healthcare systems and processes present remarkable challenges to hospitals and other types of healthcare organizations. In response to the rapid changes in the healthcare environment, interprofessional teams are becoming increasingly capable of using various problem solving techniques while bringing together unique knowledge, skills and perspectives to deal effectively with a wide range of issues. Consequently, most of the minor problems are solved routinely, collaboratively and almost instantly. Since performing the comprehensive RCA process may take considerable time and resources, ordinary problems of relatively minor importance, problems with known solutions and infrequent events with low impact should not be the subject of such a methodical approach. It is important to keep the RCA completely separate from the individual performance management process or other alternative investigations that may involve human resources, security, professional regulatory body, or police. The autonomy and integrity of the RCA process must be protected, particularly when there is a high probability of disciplinary action. There are four types of events that are generally considered inappropriate for the RCA including criminal acts, purposefully unsafe acts, suspected patient abuse of any kind, and acts related to alcohol or substance abuse. It should be pointed out that the RCA is inherently reactive process applied after an event or error occurs. In contrast, Failure Mode and Effects Analysis (FMEA) is a proactive, prospective and structured technique used to identify, assess and prevent potential product, system and process failures before they occur. The FMEA offers the apparent advantage of preventing adverse events, rather than reacting after they happen. However, both approaches have great potential to improve quality of care, enhance product, system or process reliability, reduce operating costs, eliminate or minimize risks, and build a safer healthcare system.