Common Reasons Root-Cause Analyses Fail
November 8, 2013 | Aging Services Risk, Quality, & Safety Guidance
Root-cause analyses sometimes fail to result in effective solutions. Presenting Wednesday, October 30, 2013, at the American Society for Healthcare Risk Management annual conference in Austin, Texas, on common reasons for this failure, Lisa Ramthun, CPHRM, assistant vice president of risk management, St. Joseph Health System (Orange, California), stressed that root-cause analysis is ultimately about “identifying systems-based solutions.” One reason a root-cause analysis may fail is that “event investigation is tricky,” said Ramthun. Our innate reaction to failure is to focus on active errors, hindsight bias, severity bias, and what people should or could have done. Other reasons include our propensity to stop investigating too soon, “overconfidence in our reconstructed reality,” and the incorrect belief that there is only one root cause for each event. Further, root-cause analyses must not stop at behavioral choices. “We don’t fully understand an event if we don’t see the people-involved actions as reasonable,” said Ramthun.