Root Cause Analysis

When a really bad outcome happens, the hospital undergoes a process called root cause analysis to figure out what went wrong. It's easy to point fingers at superficial or proximal elements that led to the incident, but this formal method of evaluation assures us that all contributions to a clinical event are identified.

When a root cause analysis happens, it's a big deal, committees upon committees. In this instance, a patient passed away within days of receiving a transplant. Why did this happen? Could we have avoided it? Were there misses with the pre-operative medical management, the surgical technique, or the anesthetic? What could we have done post-operatively to prevent this devastating outcome? With the scarcity of organs and donors, this was the kind of incident that really forced us to review our processes. With all the stakeholders involved - the medical transplant team, the surgeons, the medical intensive care team, the cardiothoracic critical care team, the nurses, the operating room staff, the transplant coordinators - we really probed into every possible contributor to the patient's death. I hope that this ultimately makes future transplants safer for patients.

We do a lot of transplant surgeries, and I've been in the operating room on the anesthesia side, in the pre-operative evaluation on the medical ICU side, and in the post-operative management on the CVICU side. We have so many successes; patients who have been living on home oxygen or home infusion pumps for years who walk out of the hospital. But it is the sadder, less successful outcomes that help us improve our clinical care. I wish that every patient had a perfect transplant course, but when it doesn't happen, it is our responsibility to scrutinize and fix things. I write this blog not to point out our deficiencies, but to emphasize our constant, ongoing commitment to improving patient care. Every institution has incidents like these, but I think it is important for me to be open and talk about all our stakeholders are committed to processes like root cause analysis.