If you have been in the healthcare business long enough, you have probably been involved in a Root Cause Analysis (RCA) review. If you haven't, continue to keep your fingers crossed and maybe say a prayer each morning that no harm comes to any of your patients at the hands of any of your employees. Let's be honest, we are all human beings, and we are imperfect. We all come to work to do a good job. Unfortunately, there are times that we don't, and people get hurt. In healthcare, this is not as abnormal as you would think. The CDC reports that there are 1.7 million hospital-acquired infections (HAI) annually and around 99K deaths. Twenty-two percent of the HAIs are related to surgeries. Other issues arise in surgery like wrong-site surgery, equipment malfunction, and improper use of surgical tools that cause harm. Mitigation does not begin with a root cause analysis, or at least it shouldn't. An apparent cause analysis, if completed during near-miss events, could spare you the heartache of an RCA as well as spare your patient from harm.
ACA vs. RCA
Apparent cause analysis is very much the same as the root cause analysis process. The difference is that we focus on no-harm events versus adverse events. Risk mitigation in both processes is designed to eliminate future failures. Gathering information on what happened, why it happened, & how we can prevent it from happening again are the model's foundations.
Corrective Action Plans (CAPS)
Once the information is gathered, a plan of action needs to be put into place to take corrective measures. I have found two primary tools in healthcare: D.M.A.I.C (Define, Measure, Analyze, Improve, Control) and P.D.S.A (Plan, Do, Study. Act). In both cases, maintaining change is maybe the hardest phase to manage. Re-evaluation needs to happen continually. Hard-wiring change takes time, sometimes years.
Sterile Processing Opportunities
There are innumerable amounts of events in the Central Sterile Processing Department (CSSD) that can be assessed. To list a few:
Missing instruments in surgical trays
Wrong instruments in surgical trays
Failed sterilization cycles
Improper sterilization cycles
Bioburden on surgical instruments
Wrong instruments on a case-cart
As leaders in the CSSD departments, our responsibility is to help correct failures and design processes to eliminate them.
In Conclusion
Don't mistake ACA opportunities in CSSD as just a near miss. Whether the event happened only once, there is always an opportunity for it to happen again unless we make changes.
At Evolved Sterile Processing, our consultants have a greater focus on sterile processing. With our decades of experience, we will help you develop better processes and educational resources for your staff.