A brilliant investigation and a perfunctory one converge on the same three weak fixes. The analysis explains the last failure. Only the tracker, and the engineering it forces, gets a vote on the next one.
In 2017, a team of patient-safety researchers led by Kathryn Kellogg published a study in BMJ Quality & Safety with a title that asks the question this essay is about: “Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?” They had reviewed 302 root cause analyses conducted over eight years at a major academic medical center. A root cause analysis is medicine's post-mortem: a serious adverse event happens, a team convenes, and a structured investigation produces a documented account of what went wrong and why.
Here is the number to sit with: “In 106 RCAs, solutions were proposed.”
One hundred six. Out of 302. Roughly two-thirds of these completed investigations, each triggered by a real patient coming to real harm, each conducted in full by people who cared, produced no proposed fix at all. The analysis ran to completion. The document was filed. The recommendation section, where the future was supposed to change, was empty.
And when solutions were proposed, look at what they were. Of 731 proposed solutions across the studies that had them, the most common types were “training (20%), process change (19.6%) and policy reinforcement (15.2%).” More than half of all proposed remedies fell into those three categories: teach people harder, adjust the procedure, remind everyone of the rule. The authors' conclusion was that the most frequently recommended solutions were weaker interventions, less likely to prevent recurrence. And the recurrence came: “Multiple event types were repeated in the study period, despite repeated RCAs.” The same classes of harm, happening again, at an institution that had already investigated them. Sometimes more than once.
