DOI QR코드

DOI QR Code

Guidelines for Performing Root Cause Analysis

근본원인분석 수행을 위한 지침

  • Lee, Hyeon-Jeong (Department of Preventive Medicine, College of Medicine, University of Ulsan) ;
  • Choi, Eun-Young (Department of Preventive Medicine, College of Medicine, University of Ulsan) ;
  • Ock, Min-Su (Department of Preventive Medicine, Ulsan University Hospital, College of Medicine, University of Ulsan) ;
  • Lee, Sang-Il (Department of Preventive Medicine, College of Medicine, University of Ulsan)
  • 이현정 (울산대학교 의과대학 예방의학교실) ;
  • 최은영 (울산대학교 의과대학 예방의학교실) ;
  • 옥민수 (울산대학교 의과대학 울산대학교병원 예방의학과) ;
  • 이상일 (울산대학교 의과대학 예방의학교실)
  • Received : 2017.06.01
  • Accepted : 2017.06.21
  • Published : 2017.06.30

Abstract

Root cause analysis (RCA) is systematic process for identifying contributing factors and root causes. It detects system-level vulnerabilities and prevents them from occurring in the future. In many countries, RCA guidelines have been developed and used for these purposes, and various practical tools are suggested according to stages of RCA implementation. In Korea, adverse events occur in 7.2-8.3 percent of inpatients according to studies conducted in hospitals. However, frontline staffs are suffering from lack of knowledge about RCA implementation. This study introduces RCA guidelines that may be used in hospitals to improve the quality of medical care and patient safety.

Keywords

References

  1. Patient Safety Act Article 2, Enforcement Rule of Patient Safety Act Article 2.
  2. Lee SI. Approaches to improve patient safety in healthcare organizations. Journal of the Korean Medical Association. 2015;58(2):90-92. https://doi.org/10.5124/jkma.2015.58.2.90
  3. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Quality & Safety in Health Care. 2008;17:216-223. https://doi.org/10.1136/qshc.2007.023622
  4. National Health Insurance Service, Health Insurance Review & Assessment Service. 2015 National Health Insurance Statistical Yearbook. Wonju, Korea; National Health Insurance Service, Health Insurance Review & Assessment Service; 2015.
  5. Lee SI. Development of institutional mechanism for improving patient safety in Korea. Osong, Korea: Korean Centers for Disease Control and Prevention; 2013.
  6. Shin HH. Investigation and promotion of patient safety actions at medical institutions. Seoul, Korea: Korean Institute of Hospital Management; 2015.
  7. Ministry of Health and Welfare.Korean Institute for Healthcare Accreditation. 2016 the Act on Patient Safety practice manual. Seoul, Korea: Korean Institute for Healthcare Accreditation; 2016.
  8. Jung YY. Establishment and operation plan of patient safety incident management system. Seoul, Korea: Korean Institute for Healthcare Accreditation; 2014.
  9. Wu AW, Lipshutz AK, Pronovost PJ. Effectiveness and efficiency of root cause analysis in medicine. The Journal of the American Medical Association. 2008;299(6):685-687. https://doi.org/10.1001/jama.299.6.685
  10. Parker J. editor. The Joint commission. Root Cause Analysis in Health Care: Tools and Techniques. 5th ed. Illinois, USA: Oak Brook; 2015.
  11. VA National Center for Patient Safety. Root Cause Analysis [cited 2017 Apr 10]. Available from: https://www.patientsafety.va.gov/professionals/onthejob/rca.asp.
  12. National Patient Safety Foundation. RCA2: Improving Root Cause Analyses and Actions to Prevent Harm [cited 2017 Mar 15]. Available from: http://www.npsf.org/?page=RCA2.
  13. Imperial College London. Systems Analysis of Clinical Incidents: The London Protocol [cited 2017 Apr 20]. Available from: http://www.imperial.ac.uk/patient-safety-translational-research-centre/education/training-materials-for-use-in-research-and-clinical-practice/the-london-protocol/.
  14. Canadian Patient Safety Institute. Incident Analysis [cited 2017 Mar 25]. Available from: http://www.patientsafetyinstitute.ca/en/toolsResources/IncidentAnalysis/Pages/incidentanalysis.aspx.
  15. Kawano R. Improvement for medical System by Analyzing Fault root in human ERror incident. Lee MJ, translator. Seoul, Korea: HanEon; 2014.