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Uncovering the Real Root Cause of Mistakes
It takes good detective work to get to the bottom of adverse events.
Jan Kleinhesselink, Carmen Lester
Publish Date: May 25, 2016
OR Excellence
Jan Kleinhesselink, RN, CPHQ Jan Kleinhesselink,

Speaker Profile

  • Chief quality officer at Lincoln (Neb.) Surgical Hospital.
  • AAAHC surveyor.
  • Has been in surgical leadership roles for more than 25 years.
Carmen Lester, RN, JD Carmen Lester, RN, JD

Speaker Profile

  • Chief clinical officer of Lincoln (Neb.) Surgical Hospital.
  • Received law degree from the University of Nebraska College of Law.
  • Member of American Organization of Nurse Executives and the American College of Healthcare Executives.

Jan Kleinhesselink, RN, CPHQ, and Carmen Lester, RN, JD, work down the hall from each other at the Lincoln (Neb.) Surgical Hospital, where part of their responsibilities involves investigating why adverse events occur and what can be done to prevent them from happening again. In their ORX presentation "True Detective: Uncovering the Real Root Cause," the always-entertaining duo will discuss how medical errors aren't always what they appear to be and how uncovering the actual factors that lead to mistakes demands shifting away from a narrow focus on the obvious issues.

  • Drilling down is difficult. As leaders, you have the best intentions in trying to determine how to fix a problem. But you sometimes determine "the fix" using your own biases, perspectives, experiences and agendas, which can lead you to formulate the solution to a problem before ever taking the time to drill down to the exact causes. Or maybe a time constraint becomes a factor in the analysis, so you determine the solution first — instead of last — and work backward to justify that your solution is the correct fix.
  • Avoid the narrow perspective. You can't solve a problem by only looking at a brief snapshot in time. The image you're looking at is only a small portion of the larger picture. It's easy to fall into the pattern of making a knee-jerk decision to fix the current problem at hand but, in reality, that problem is only a tiny symptom of a much larger, complex concern. If you try to fix only the issue directly in front of you without zooming out to see what other systems are involved or affected, you'll end up with a bunch of Band-Aids on a giant, broken process.
  • Diving deep. There is certainly a textbook methodology to proper root cause analysis that includes determining the frequency, severity and outcome of the problem. You have to consider whether the event was isolated or part of a trend, how likely it is that the event could happen again, the harm severity — minor or major injury or potential for injury — and the worst-case scenario. You have to have a solid understanding of the processes involved in order to perform an effective analysis and avoid a quick-fix solution.
  • Communication is key. Just when you think you have communicated enough with your staff, communicate some more. Make the communication meaningful — it's not enough to send a memo or hang reminders throughout the facility. You need to really engage your staff in the conversation and make sure you're listening to their feedback.
  • Making change happen. Monitor the lessons and solutions that have been implemented. This is a step that many administrators forget to follow up on. Go back and see if minor adjustments are needed to ensure that there will not be a recurrence. OSM