A Multicentered Academic Medical Center Experience of a Simulated Root Cause Analysis (RCA) for Hematology/Oncology Fellows

We report on a multicentered experience utilizing a simulated RCA educational module in an attempt to provide fellows with the tools needed to participate in a live RCA and to increase awareness of the need to analyze patient safety events. The 2-h module included a didactic session explaining the basics of an RCA including common terminology, effective chart review, and personal interviews. The fellows assessed a patient safety event of a missed coagulopathy and created an event flow map and fishbone analysis. They then formed root cause/contributing factor statements and proposed a solution. Twenty-three fellows from two institutions completed the experience. There was a significant difference in fellow reported comfort with participating in a live RCA (p = 0.03), and in utilizing the tools of an RCA following the mock RCA experience (p = 0.005). About 70% of respondents felt that as a result of the mock RCA, they were more likely to report a near miss or adverse event and were more likely to be thorough in their documentation. Mock RCAs are a feasible method of incorporating ACGME-required patient safety activities into hemat ology/oncology fellow education and are effective in increasing their comfort and understanding of important quality improvement skills.
Source: Journal of Cancer Education - Category: Cancer & Oncology Source Type: research