Root cause analysis of cases involving diagnosis
Mark L. Graber, Gerard M. Castro, Missy Danforth, Jean‐Luc Tilly, Pat Croskerry, Rob El-Kareh, Carole Hemmalgarn, Ruth Ryan, Michael P. Tozier, Bob Trowbridge, J. O. Wright, Laura Zwaan
Abstract
Diagnostic errors comprise the leading threat to patient safety in healthcare today. Learning how to extract the lessons from cases where diagnosis succeeds or fails is a promising approach to improve diagnostic safety going forward. We present up-to-date and authoritative guidance on how the existing approaches to conducting root cause analyses (RCA's) can be modified to study cases involving diagnosis. There are several diffierences: In cases involving diagnosis, the investigation should begin immediately after the incident, and clinicians involved in the case should be members of the RCA team. The review must include consideration of how the clinical reasoning process went astray (or succeeded), and use a human-factors perspective to consider the system-related contextual factors in the diagnostic process. We present detailed instructions for conducting RCA's of cases involving diagnosis, with advice on how to identify root causes and contributing factors and select appropriate interventions.