12. Root Cause Analysis: instrument for reactive risk analysis

Summary

Systematic Incident Reconstruction and Evaluation (SIRE) is a structured way to reconstruct (what happened?) and evaluate (why did it happen?) an incident. (4) The objective is to answer the question: how can a similar incident be avoided in the future? SIRE accomodates the need to learn from incidents and to take concrete and practical measures to lower the risk that similar incidents can recur.

SIRE, also known as Root Cause Analysis (RCA), has been used successfully in aviation and industry for decades and in health care since the end of the 1990s. The methodology is carried out in steps, is multidisciplinary and the question of guilt is irrelevant. The root causes are sought until they can be assigned and the overall objective is to prevent the repetition of (similar) incidents. The philosophy behind SIRE is that humans will continue to make errors but that something can be learned from these errors so that they will be discovered or caught on time in future before they lead to harm.

The purpose of this chapter is to acquaint the reader with SIRE and explain how SIRE is currently applied in the Netherlands. It is advisable to attend a SIRE training course or to read the book, “Patient safety; Systematische Incident Reconstructie en Evaluatie” [Patient Safety; Systematic Incident Reconstruction and Evaluation] or a book on RCA before using SIRE. (21)

SIRE consists of seven steps:

1. Collect information; the investigator collects as many facts as possible on the incident;

2. Organise the information; the investigator creates an overview of the incident so it can be seen as a film before one’s eyes;

3. Define research area; the investigator decides where research will be focused and defines the limits of the research area;

4. Identify causes; the investigator identifies the causes and influencing factors that made the incident possible;

5. Devise safety and quality improvements; the investigator devises useful and feasible recommendations to avoid repetition of similar incidents;

6. Report; the investigator writes a concise report of his findings and recommendations based on which third parties (e.g. management) can take conscious decisions; and

7. Complete; everyone who was involved with the incident and/or SIRE is informed about the result.

> SIRE provides an objective description of the incident investigated and the basic causes and influencing factors that played a role in it. (22) SIRE thereby offers the people involved in the incident insight into all factors that contributed to the incident: their own role, the preceding steps, the further development and the influence of their actions. This insight is then placed within the context of that moment. Therefore, SIRE does not stop as soon as it is discovered what has gone wrong. It investigates why such a decision was made at that moment or why a specific action was taken. What should have been done differently at that time to keep those involved on the right path? With this insight, the individuals involved, supported by the SIRE investigator, can devise useful and practicable measures to prevent a repetition of similar incidents.

> SIRE not only offers recommendations for measures to prevent similar incidents, but also contributes to employee insight into incidents in general. Employees who are involved with SIRE will thereby become more “error-wise”. They will be able to detect the foreboding of an incident sooner and change course to prevent that incident. Moreover, they will be in a better able to understand the pathofysiology of an incident. As a result, they will feel more comfortable talking openly about errors and unsafe situations.

> A third benefit is that SIRE generates data on the causes of incidents. These data are easy to transfer to existing classification systems and can be made accessible for research by using a database.

Against these pros, there are also some cons:

- first, SIRE requires a considerable time investment;

- second, not every employee is suitable to carry out a SIRE. The SIRE investigator must be steadfast to continue to ask questions, even with difficult people. Analytic ability, a constructive critical attitude and writing skills are also essential. Clinical experience is an advantage, but does not appear to be necessary; and

- finally, although common sense leads one to believe that SIRE contributes toward improving patient safety, it has not yet been scientifically demonstrated. This is currently under investigation at UMC Utrecht.