Virtually all healthcare organizations prior to the 1999 publication of the Institute of Medicine's landmark report, To Err is Human, engaged in investigations of events that caused harm to patients. Few of these investigations, however, engaged in a systems-based approach to problem solving.

The focus was on individuals and mistakes, rather than on the cluster of events that had combined in an unfortunate sequence to cause an incident to occur. Based on a "name and blame" culture, the emphasis of such investigations was not on prevention, but on punishment.

By shifting the goal from eliminating errors to reducing or eliminating harm to patients - through investigating the viability of medical care systems, rather than focusing on individual acts - much has been accomplished at VA.

Our goal is simple: The reduction and prevention of inadvertent harm to our patients as a result of their care.

Reducing or eliminating harm to patients is the real key to patient safety. Efforts that focus exclusively on eliminating errors will fail. We'll never eliminate all individual errors. The goal is to design systems that are "fault tolerant," so that when an individual error occurs, it does not result in harm to a patient.

That's why we've based VA's patient safety program on a systems approach to problem solving - focused on prevention, not punishment. We use methods and apply ideas from "high reliability" organizations, such as aviation and nuclear power, to target and eliminate system vulnerabilities.

For instance, the fault-tolerance principle has been used for years by high-reliability organizations when designing systems, and the safety records of such organizations far surpass those of healthcare.

We don't target people; we don't want to participate in the "name and blame" culture of the past. We look for ways to break that link in the chain of events that can create a recurring problem: those underlying systems-based problems that went ignored or unaddressed.

One of the most important ways to do this is to learn from close calls, sometimes called "near misses," which occur at a much higher frequency than actual adverse events. Addressing problems in this way not only results in safer systems, but it also focuses everyone's efforts on continually identifying potential problems and fixing them.

This doesn't mean that VA is a "blame free" organization. We have a system that delineates what type of activities may result in blame and which don't. Only those events that are judged to be an intentionally unsafe act can result in the assignment of blame and punitive action. Intentional unsafe acts, as they pertain to patients, are any events that result from a criminal act, a purposefully unsafe act, or an act related to alcohol or substance abuse or patient abuse.

The integration of these approaches across the organization creates a level of trust and a focus of efforts that helps perpetuate a culture of safety.

The Department of Veterans Affairs National Center for Patient Safety was established in 1999 to lead the VA's patient safety efforts and to develop and nurture a culture of safety throughout the Veterans Health Administration.

Our multi-disciplinary team is located in Washington, DC, Ann Arbor, MI, and White River Junction, VT. We offer expertise on an array of patient safety and related health care issues. Patient safety managers in all 154 VA hospitals actively participate in the program, as well as do patient safety officers in all 21 network headquarters.

We use a multi-disciplinary team approach, known as Root Cause Analysis - RCA - to study health care-related adverse events and close calls.

The goal of the RCA process is to find out what happened, why it happened and to determine what can be done to prevent it from happening again. Because our Culture of Safety is based on prevention, not punishment, RCA teams investigate how well patient care systems function. We focus on the "how" and the "why" ? not on the "who".

Because people on the frontline are usually in the best position to identify issues and solutions, RCA teams at VA health care facilities formulate solutions, test, implement, and measure outcomes in order to improve patient safety. See below to learn more about the RCA process ...

The goal of a Root Cause Analysis is to find out

• What happened
• Why did it happen
• What to do to prevent it from happening again.

Root Cause Analysis is a tool for identifying prevention strategies. It is a process that is part of the effort to build a culture of safety and move beyond the culture of blame.

In Root Cause Analysis, basic and contributing causes are discovered in a process similar to diagnosis of disease - with the goal always in mind of preventing recurrence.

Root Cause Analysis is:

1. Inter-disciplinary, involving experts from the frontline services
2. Involving of those who are the most familiar with the situation
3. Continually digging deeper by asking why, why, why at each level of cause and effect.
4. A process that identifies changes that need to be made to systems
5. A process that is as impartial as possible

To be thorough a Root Cause Analysis must include:

1. Determination of human & other factors
2. Determination of related processes and systems
3. Analysis of underlying cause and effect systems through a series of why questions
4. Identification of risks & their potential contributions
5. Determination of potential improvement in processes or systems

To be Credible a Root Cause Analysis must:

1. Include participation by the leadership of the organization & those most closely involved in the processes & systems
2. Be internally consistent
3. Include consideration of relevant literature

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