Root Cause Analysis as an Opportunity to Improve the Safety of Perinatal Care: Analysis of a Nosocomial Infection Outbreak

Abstract

Patient safety is a serious global public health issue. The causal analysis with a systematic and participatory approach is a useful tool for improving safety. OBJECTIVE: to perform the causal analysis of a sentinel event in order to identify improvement opportunities, propose actions aimed at increasing patient safety and promote a collaborative approach by the health team. METHODS: Root Cause Analysis (RCA) of a sentinel event occurred in the Neonatal Intensive Care Unit of Hospital Penna de Bahía Blanca, Argentina, which included the following steps: 1) identification and selection of the event; 2) information collection and description of the event; 3) construction on the map of the facts; 4) analysis of contributing factors and study of the barriers (physical, administrative, organizational) that may prevent damage, 5) Developing solutions and action plan. RESULTS: an intrahospital methicillin-resistant Staphylococcus aureus outbreak that affected six newborns and caused one death was selected. The causal analysis permitted the identification of proximal human factors as well as latent system failures associated with organizational factors and factors related to information management, context management and corporative culture. Appropriate communication between health professionals and systematization of processes aimed at guarantying personal adherence to bio-security norms were identified as the main barriers. Interventions oriented to strengthen these barriers were proposed. CONCLUSIONS: ACR is a feasible method to be implemented by the health team. Its use permitted patient safety improvement through the identification and correction of the latent failures of the system.