Introduction

Root cause analysis (RCA) investigates and categorizes the events that affect safety, quality, reliability, and production of health care services.1 It helps to identify not only what and how an event occurred, but why it happened.2 Generally, “human errors” can be traced to some well-defined causes.3 Understanding the reasons why these events occur is the key to developing effective recommendations and to specifying workable corrective measures to prevent future adverse events.

RCA implementation consists of 7 critical steps (figure).4 The aim is to recognize that prevention of recurrence by a single intervention is not always possible because there may be several root causes for a particular situation. RCA is often considered an iterative process, and it is viewed as a tool for continuous quality improvement.5 Although its potential in health care is now being realized, RCA has been implemented successfully for decades in manufacturing and aviation.6–9

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Market forces along with internal pressure from organizations dedicated to patient safety have ushered in a new era in medicine focused on enhancing the quality of care.3,10–13 Accordingly, innovations in medical education must be nurtured to develop physicians equipped with the knowledge and tools to cultivate a culture of quality. Yet, traditional quality improvement strategies in graduate medical education have been largely reactive in nature.14–16 Often, such “after-the-fact” analyses of medical errors focus on individual accountability and reprimand, which are ineffective methods of enhancing patient safety and seldom help to improve the overall quality of care.17–19

In an effort to transform graduate medical education, the Accreditation Council for Graduate Medical Education (ACGME) issued 6 guiding principles as part of its Outcome Project.20 Two of these competencies—systems-based practice, and practice-based learning and improvement—have direct implications on health care quality and call for a shift from narrow, discipline-specific views of patient care to an integrated model that enhances organizational excellence.21,22 As these concepts have matured, so has the expectation that training programs will meet the challenge by teaching residents to systematically analyze practice with quality improvement methods, implement change strategies with the goal of practice improvement, work in interprofessional teams to enhance patient safety, and participate in the identification of “systems” errors with the goal of implementing “systems” solutions.23 And although “error reduction” has received significant attention within the medical education community, there is limited research on novel methods to empower residents to meaningfully improve quality.

In recent years, simulation has emerged within residency programs as a valuable tool to attain basic technical adeptness and to improve resident performance in medical procedures.24 Limited evidence also suggests that simulation is a useful means of preparing physicians to function more effectively within the context of multidisciplinary care teams and to build leadership skills for crisis resource management.25–29 We sought to assess the effectiveness of high-fidelity simulation as a proactive tool for teaching RCA in graduate medical education to assist physicians-in-training to identify and manage systems-based obstacles that may impede optimal patient care.

Methods

Results

Knowledge and Attitude Assessments

All participants completed the entire study (n  =  30). Baseline demographics were similar between groups in terms of average age, sex, and level of training.

Self-Reported Assessments

Ninety-three percent of the participants (n  =  28) reported that they had not heard of RCA prior to this exercise, and 13% (n  =  4) had not heard of systems improvement theory. At baseline, participants reported similar low scores regarding their understanding of systems improvement (P  =  .28) and RCA (P  =  .09). After intervention, all participants reported similar markedly higher scores regarding their understanding of systems improvement (P  =  .82) and RCA (P  =  .50). At 6-month follow-up, all participants continued to report a high level of understanding of systems improvement (P  =  .81) and RCA (P  =  .25; table 1).

TABLE 1 Self-Reported Knowledge of Root Cause Analysis (RCA) and Systems Theory

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Objective Knowledge Assessments

Initial knowledge scores related to systems improvement and RCA remained consistent with baseline self-reported scores (P  =  .28). Postintervention assessment demonstrated similar improvement in knowledge scores among both groups (P  =  .84). At 6-month follow-up, knowledge scores were significantly lower among members of group B (P  =  .001; table 2).

TABLE 2 Objective Knowledge Assessment ^a

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Attitude Evaluation

Initial evaluation of attitudes toward systems improvement and RCA were similar between groups (P  =  .67); however, immediate postintervention scores revealed that group B members were significantly less likely to accept systems improvement strategies and the use of RCA to improve health care quality (P < .001). At 6-month follow-up, members of group A continued to express positive attitudes toward the use of systems improvement strategies and RCA, whereas members of group B remained significantly less likely to do so (P < .02; table 3).

TABLE 3 Attitude Toward “Systems Improvement” and Root Cause Analysis (RCA) ^a

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Simulation Intervention

During the simulation exercise, the volunteers in each group A subgroup initially attempted to pharmacologically control the hypertension and tachycardia. With limited success and persistent ST changes on the electrocardiogram, they worked with the care team to abort the procedure. In addition, all subgroups initiated some form of a myocardial infarction protocol and recommended that the patient be transferred to the intensive care unit to commence an appropriate cardiac work-up and to determine further management. The root causes and potential corrective measures identified after the debriefing session (table 4) support the notion that group A understood the concept of RCA and systems thinking, and was successful in applying the concepts to a real-world scenario.

TABLE 4 Identified Root Causes and Proposed Corrective Strategies ^a

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Discussion

Simulation has been increasingly used in medical education as a means to safely and objectively develop resident knowledge and skills.24 From simple, individualized modules to elaborate, team-based exercises, a myriad of simulation experiences are potentially available.26,30 An appreciation and understanding of the most common simulation methods as well as their strengths and weaknesses can assist educators in developing a more diverse training portfolio.

The results of our study suggest that high-fidelity simulation, paired with succinct didactics, is a novel and effective method for teaching RCA and systems thinking to residents. Study limitations include small sample size and single-site intervention, and our study lacked validated and standardized measures. Consequently, these results are not necessarily generalizable to other institutions. In addition, we used only one clinical scenario directly involving a pair of residents from the same specialty, which undermines the teamwork development, cross-specialty training, and multiple-scenario capabilities of high-fidelity simulation. Our group is in the process of developing more elaborate scenarios that incorporate these features.

The use of simulation in continuous quality improvement offers several advantages over traditional (reactive) or didactic methods. First, it does not rely on accidental harm to patients to allow for an educational opportunity, thereby enabling residents to experience even clinically rare events (eg, malignant hyperthermia); second, it provides a “safe” environment in which residents can practice responding to critical situations autonomously without potential harm to patients; third, feedback is instantaneous; and fourth, a large number of clinical scenarios can be constructed to meet the educational goals of each session. Aside from these direct advantages and despite direct costs related to acquisition and operation of equipment, there exists the likelihood for overall cost savings through error reduction. However, the most important advantage of high-fidelity simulation is rooted in the experiential learning that it fosters. Popularized by Kolb, the essence of experiential learning is best summarized by a famous dictum attributed to Confucius, which states: “Tell me, and I will forget. Show me, and I may remember. Involve me, and I will understand.” Experiential learning occurs when individuals engage in an activity, reflect upon the activity critically, derive some useful insight from the analysis, and incorporate the result through a change in understanding and/or behavior.31

Unlike in manufacturing or aviation, where RCA is used routinely to achieve the highest degree of mechanical precision, human interaction and subjective decision making are critical components of medical care; highly trained and well-intentioned individuals will make mistakes, but the expertise, compassion, and emotional intelligence they possess are not easily replaced. Therefore, it is important to ingrain mechanisms that attenuate the impact of errors and to implement continuous quality improvement efforts to persistently refine existing systems. Given limited opportunities to introduce residents to important concepts such as systems improvement and RCA, educational sessions aimed at such topics should maximize their impact through the use of experiential learning (such as high-fidelity simulation) in addition to focused didactics. Moreover, the use of high-fidelity simulation as a complement to lectures on health care management theory represents a unique opportunity to reinforce the core concepts emphasized in the 2011 ACGME Common Program Requirements.23 Although we were able to demonstrate good short-term retention of knowledge and sustained positive attitudes toward RCA and systems thinking, further work must determine whether this can be sustained over the long term. Future research should also attempt to prospectively estimate the impact of simulation-based RCA education in terms of overall resident error reduction and the severity/nature of medical errors that do occur.