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Implementing a Root Cause Analysis Program to Enhance Patient Safety Education in Urology Residency

  • Andrew M. Harris
    Correspondence
    Address correspondence to: Andrew M. Harris, M.D., University of Kentucky Medical Center, 800 Rose St, Lexington, KY 40536-0298.
    Affiliations
    Department of Urology, University of Kentucky College of Medicine, KY
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  • Author Footnotes
    # Justin Ziemba, MD, Perelman Ceneter for Advanced Medicine, West Pavilion, 3rd Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104.
    Justin Ziemba
    Footnotes
    # Justin Ziemba, MD, Perelman Ceneter for Advanced Medicine, West Pavilion, 3rd Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104.
    Affiliations
    Division of Urology, Hospital of the University of Pennsylvania, PA
    Search for articles by this author
  • Author Footnotes
    † Jason Bylund, MD, MPH, University of Kentucky Medical Center, 800 Rose St, Lexington, KY 40536-0298.
    Jason Bylund
    Footnotes
    † Jason Bylund, MD, MPH, University of Kentucky Medical Center, 800 Rose St, Lexington, KY 40536-0298.
    Affiliations
    Department of Urology, University of Kentucky College of Medicine, KY
    Search for articles by this author
  • Author Footnotes
    # Justin Ziemba, MD, Perelman Ceneter for Advanced Medicine, West Pavilion, 3rd Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104.
    † Jason Bylund, MD, MPH, University of Kentucky Medical Center, 800 Rose St, Lexington, KY 40536-0298.
Published:January 21, 2020DOI:https://doi.org/10.1016/j.urology.2019.11.059

      ABSTRACT

      OBJECTIVE

      To describe and assess the implementation and effectiveness of a RCA based program in Urology residency. The Accreditation Council for Graduate Medical Education states programs should encourage patient safety (PS) and provide formal PS education. However, data suggests most programs fall short. Root Cause Analysis (RCA) has been established as an effective method for event analysis and PS.

      METHODS

      A RCA program was designed to analyze and discuss PS events in our department. This began with an educational session about RCA methodology. Subsequently, teams composed of faculty and residents were charged with selecting an adverse event to present at our monthly PS conference. Over a 6-month period, each team presented a recent complication, event timeline, and fish bone diagram.

      RESULTS

      A RCA was completed and presented following adverse outcomes: fascial dehiscence, neonatal urosepsis, superior mesenteric artery ligation, pyelonephritis after ureteroscopy, and surgical site infection. Quantitative peer assessment of the presentations demonstrated aptitude in selecting an appropriate case (mean Likert scale score of 4.8/5), prioritizing important factors (score: 4.85), defining root causes (score: 4.9/5), and proposing solutions (score: 4.65/5). The qualitative feedback assessment noted the value of critical thinking to reduce complications, with the greatest limitation being time constraints. In addition, suggestions for improving the process included inclusion of ancillary staff involvement and selection of topics with modifiable solutions.

      CONCLUSION

      RCA can be used as an educational tool for practice-based learning and improvement education. The program was well received and will continue in our department.
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