Common Cause Analysis and Audits Help Medical Center Reduce Adverse Surgical Events

A medical center reduced its rate of wrong-site, wrong-procedure, and wrong-patient surgical events by developing processes to address specific failure modes identified during a common cause analysis and observational audit program, according to the results of a study published in the January/February 2012 issue of the American Journal of Medical Quality. Between April 2008 and January 2010, the facility experienced eight wrong-site, wrong-procedure, or wrong-patient surgical events, and a root-cause analysis was conducted for each. The common cause analysis, which was conducted to help the facility recognize trends and establish themes identified from each root cause analysis, identified 22 occurrences of failure modes noted in the category of “Rules, Policies, and Procedures” and 17 failure modes present in the category of “Human Factors: Scheduling and Fatigue.”