Improving Patient Safety: Root Cause Analysis Training for Fourth Year Geriatric Sub-Interns

This curriculum was developed to teach students one of the primary tools used for quality improvement in healthcare, root-cause analysis.

Overall things to complete (described in additional detail in the remainder of this document):

  1. Take the online coursework (IHI website)
  2. Perform a basic root-cause analysis of one of the cases developed by the geriatrics department.
  3. Discuss the ways various aspects of the case relate to specific competencies in the AAMC’s list of Geriatric Competencies
  4. Present the case, your analysis, and an overview of the process of a root-cause analysis to the department at a case conference near the end of the elective.

In more detail:

  1. As an introduction to the process of root-cause analysis, you will take an online course at the institute for healthcare improvement (IHI).

Steps: Note that this may be a part of your schedule with a preceptor (check with Travis if unsure).

  1. Go to
  2. Make a new account (Log in/register link in upper right corner)
  3. Once you are registered and logged in, go to
  4. About halfway down the page, in the patient-safety section, click on the course PS 104: Root Cause and Systems Analysis. (Do not confuse with the course QI 104, very different) and complete the lessons, along with their questions and quizzes. You have to get a certain score on the quizzes to pass, but you can retake them.
  1. Perform a root-cause analysis on a case given to you. You will be given (or maybe you already have) a sheet with the basics of a case that involved some adverse event. You will interview the member of the geriatrics faculty who authored the case. It is helpful to have worked through as much of the RCA process as you can before meeting with the faculty member, as it helps direct your questions. Make a fishbone diagram, recommend specific actions, etc. You do not need to come up with a summary discussion.
  2. During your interview with the faculty member, you will also discuss the geriatric competencies related to this case. In preparation for this, review the AAMC’s Geriatric Competencies list, which will be provided to you, and consider 3-4 competencies that relate to this case. Note that you are not expected to master these competencies by means of the case; rather, the point is to demonstrate that specific competencies on the list would be useful for addressing the needs of the patient in your case (this does not suggest that the people involved in the case were not proficient in these competencies; they generally were).
  3. Present the case, analysis, and RCA process at the case conference. A simple idea, but it is a little difficult to tailor this for your audience, which is variable. A good number of the Geriatrics faculty will be there, and they are all familiar with the RCA process (and possibly with the case as well); however, PA’s, pharmacy students, and med students all rotate through the geriatrics program at different times, and there will be a few of them at your presentation. They probably will have little to no previous exposure to RCA’s. It is a good idea to briefly introduce the topic of RCA at the beginning of your presentation for their benefit.

Some helpful reference information for each step of a Root Cause Analysis

Steps in the RCA that you have to do:

  1. Make a timeline
  2. Consider as many contributing factors as possible and make a fishbone diagram.
  3. Form causal statements.
  4. Make recommendations.

The steps are straightforward. When doing the project, though, it is nice to have some of the information from the IHI tutorial at your fingertips, rather than having to go back through the lesson, so here is some additional info:

Timeline: I think this is obvious. Make a timeline.

Fishbone diagram: One of the most important parts of the Root Cause Analysis because it helps the investigator to form ideas of possible contributing factors, and it is important to have some ideas of what you are looking for when you start the research (or your interview with the faculty). It also helps organize the contributing factors.

I also found it helpful to have some reminders of what sorts of things fall into which categories:

Below is reproduced the table from the 1998 Vincent article.

  1. Institutional context:
  2. Economic and regulatory context
  3. National Health Service Executive
  4. Clinical negligence scheme for trusts
  5. Organizational and management factors
  6. Financial resources and constraints
  7. Organizational structure
  8. Policy standards and goals
  9. Safety culture and priorities
  10. Work Environment
  11. Staffing levels and skills mix
  12. Workload and shift patterns
  13. Design, availability, and maintenance of equipment
  14. Administrative and managerial support
  15. Team factors
  16. Verbal communication
  17. Written communication
  18. Supervision and seeking help
  19. Team structure
  20. Individual (staff) factors
  21. Knowledge and skills
  22. Motivation
  23. Physical and mental health
  24. Task factors
  25. Task design and clarity of structure
  26. Availability and use of protocols
  27. Availability and accuracy of test results
  28. Patient characteristics
  29. Condition (complexity and seriousness)
  30. Language and communication
  31. Personality and social factors

(Vincent C, Taylor-Adams S, and Stanhope N, Framework for analysing risk and safety in clinical medicine. BMJ 1998 316 (7138):1154-7. Accessed via JSTOR).

Causal statements: Recall that these start with one of the factors identified in the fishbone. Below is reproduced the example causal statement from IHI:

Lack of a patient dementia protocol: The current practice of the busy general medical unit to rely on patients to advocate for themselves did not support a patient with dementia, whose co-morbid cognitive difficulties reduced her ability to communicate with staff and advocate for her own needs during respiratory therapy and hospital transportation. This led to inadequate information about her respiratory needs, increasing the likelihood of insufficient oxygenation during transport.

I have found in my limited experience that causal statements themselves frequently suggest what one of the recommendations will be, in a rather obvious manner.

Recommendations types: These can be stronger or weaker. Remember that the effect of the actions ought to be measurable. Below are the different classes of recommendations and their relative ability to effect meaningful change in outcomes. (from the National Center for Patient Safety,

Stronger actions

  • Architectural/physical plant changes
  • New device with usability testing before purchasing
  • Engineering control or interlock (forcing functions)
  • Simplify the process and remove unnecessary steps
  • Standardize on equipment or process or caremaps
  • Tangible involvement and action by leadership in support of patient safety

Intermediate Actions

  • Increase in staffing/decrease in workload
  • Software enhancements/modifications
  • Eliminate/reduce distractions (sterile medical environment)
  • Checklist/cognitive aid
  • Eliminate look and sound alikes
  • Read back
  • Enhanced documentation/communication
  • Redundancy

Weaker Actions

  • Double checks
  • Warnings and labels
  • New procedure/memorandum/policy
  • Training
  • Additional study/analysis